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The bacteraemia service model of infection care
- Gavin D Barlow, Patrick Lillie, Specialist Registrar in Infectious Diseases/Medicine, Royal Hallamshire Hospital, Glossop Road, Sheffield, S10 2FJ (25 February 2008)
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Early treatment strategies in sepsis
- Mohammed A Butt, Coulson AK, F2 medicine, Hull JH, SpR Respiratory Medicine, Ho TBL, Consultant Respiratory Physician (26 February 2008)
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A quality improvement?
- Martin J Sheppard (3 March 2008)
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Early Management of Sepsis
- Daniel G Boden (7 March 2008)
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Gavin D Barlow, Consultant in Infectious Diseases/Medicine Hull & East Yorkshire Hospitals NHS Trust, Castle Hill Hospital, East Yorkshire, HU16 5JQ, Patrick Lillie, Specialist Registrar in Infectious Diseases/Medicine, Royal Hallamshire Hospital, Glossop Road, Sheffield, S10 2FJ
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Dear Editor – We strongly support Minton and colleagues’ call for better care of patients with bacteraemia1. We implemented a similar service in June 2005. This provides unsolicited bedside reviews and a type -written report for all patients with bacteraemia. During an 18 month pilot period (June 2005 to November 2006), 151 adults were reviewed. Of 174 isolates, the most common was Staphylococcus aureus (45%) of which 40% were meticillin-resistant (MRSA); the most common source was central venous lines (27% of patients). For hospital-acquired bacteraemia therefore, the report is now sent to the trust’s medical director and forms part of the root-cause analysis. Despite a high pre-consultation level of appropriateness (based on sensitivity data) of the antibiotic prescriptions (87%), 62% still required optimisation at review; our high pre-consultation appropriateness may have been due to an accessible and well recognised trust-wide antibiotic guideline. The number of prescriptions for broad-spectrum agents decreased from 41 before to 24 after consultation with intermediate-spectrum (58 to 68) and narrow- spectrum (81 to 87) prescriptions increasing. Further investigations were suggested in 60%. We also identified 13 patients with clinically significant mono-bacteraemia due to coagulase-negative staphylococci, often assumed to be contaminants. In this heterogeneous cohort, mortality at 30 days was 19% with 9 patients (7%) suffering confirmed recrudescence by 90 days. Provision of the service required 60 hours of doctors’ time. The most important thing we have learned is that phone or end of the bed advice is sub-optimal in bacteraemia; the history must be retaken, the patient carefully examined, and investigations and drug chart reviewed. Whether those providing this are microbiologists, infectious diseases physicians, acute medics, intensivists, or collaborations thereof is not important, providing they have the necessary clinical skills. Given the poor knowledge junior doctors have about sepsis2, we have also found on- the-job teaching to be beneficial. As Godlee intimates3, it is unlikely that uncontrolled before and after studies will convince policy-makers or hospital managers to invest in the bacteraemia service model of care, but this or similar models must represent the future of infection practice in the UK; a move away from the traditional, but under-utilised solicited consultation and infection diseases unit approach to roving teams of infection experts providing unsolicited consultations for all hospitalised patients with infection. As demonstrated above, this can integrate well with government policy on hospital-acquired infections, but will require a fundamental shift in the way clinical infection services are organised in the UK. The cost-effectiveness of this approach should be investigated urgently as part of the research for patient benefit agenda. Correspondence to: Gavin.Barlow@hey.nhs.uk References 1. Minton J, Clayton J, Sandoe J, McGann H, Wilcox M. Improving early management of bloodstream infection: a quality improvement project. BMJ 2008;336:440-443 (23 February), doi:10.1136/bmj.39454.634502.80 2. Ziglam HM, Morales D, Webb K, Nathwani D. Knowledge about sepsis among training-grade doctors. J Antimicrob Chemother 2006;57:963-965 2. Godlee F. Editor’s Choice. BMJ 2008;336 (23 February), doi:10.1136/bmj.39497.574525.DE Competing interests: None declared |
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Mohammed A Butt, ST2 general medicine Knight Centre for Cystic Fibrosis, Dept. of Respiratory Medicine, Frimley Park Hospital GU16 7UJ, Coulson AK, F2 medicine, Hull JH, SpR Respiratory Medicine, Ho TBL, Consultant Respiratory Physician
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Minton et al add to a gathering body of evidence that poor clinical practice in the initial management of patients with bloodstream infections may contribute to increased morbidity and mortality [1]. The international Surviving Sepsis Campaign guidelines recommend early therapy with appropriate fluid resuscitation and timely antibiotic administration when managing patients with septicaemia [2]. The importance of rapid antibiotic administration in sepsis has long been recognised. In the case of meningitis, evidence exists that earlier antibiotic therapy even prior to admission reduces mortality [3]. In UK hospital practice, delay in administration of treatment may arise for a number of reasons. Clinician factors include time to assess and prescribe treatment, and time to site an intravenous line. Nursing factors relate to availability to dispense treatment, availability of other staff to double- check prescriptions and bed moves due to patients breaching the 4-hour wait in accident and emergency. We recently performed a retrospective study of sequential patients with community acquired pneumonia and septicaemia transferred within 48 hours of admission to a district general intensive care unit over a one year period. Variables analysed included age, sex, smoking status, CURB 65 score, time from initial review to antibiotic administration, whether intravenous fluid was given in the first 4 hours and admission lactate. Outcomes were death or discharge from hospital. Thirty-five patients’ notes were reviewed retrospectively. Mean age was 59 (range 14-96). 54% (19) were males and 69% (24) had a documented history of smoking. Patients aged over 65 had a 53% (9 of 17) mortality rate compared with 22% (4 of 18) of those under 65. Smokers had a 46% (11 of 24) mortality rate compared with 18% (2 of 11) in non-smokers. CURB 65 scores were grouped 0/1, 2/3 and 4/5. In both the 0/1 and 2/3 groups mortality was identical at 30% (3 of 10 and 6 of 20 respectively). Patients scoring 4/5 on admission however had 80% (4 of 5) mortality. The general trends of progressively increasing mortality with increased delay to first antibiotic and increased admission lactate are seen in Figure 1. The survival benefit of aggressive fluid resuscitation is also displayed. The findings suggest that timely administration of antibiotics and intravenous fluids in this setting is important. An additional strategy to those described by Minton et al to achieve this may be to encourage junior doctors to administer the first dose of antibiotic themselves for suspected sepsis. Although this adds an extra task for junior doctors it ensures the first dose is promptly administered. In our hospital we recommended the use of a sepsis box in acute assessment areas, localising all the necessary equipment and guidelines for sepsis treatment. We also noted that patients with admission CURB 65 scores of 4/5 had markedly higher mortality rates than those with lower scores. The correlation seen between admission lactate and mortality suggests that it may be an important assessment factor. We believe that early recognition tools as described by Minton et al and an increased awareness of the Surviving Sepsis Campaign guidelines will improve patient outcomes [4]. References [1] Minton J, Clayton J, Sandoe J, McGann H, Wilcox M. Improving early management of bloodstream infection a quality improvement project. BMJ 2008; 336:440-3 [2] Dellinger RP, Carlet JM, Masur H, et al. Surviving Sepsis Campaign guidelines for management of severe sepsis and septic shock. Crit Care Med 2004; 32:858-73 [3] Cartwright K, Reilly S, White D, Stuart J. Early treatment with parenteral penicillin in meningococcal disease. BMJ 1992: Jul 18;305(6846):143-7. [4] Gao F, Melody T, Daniels DF, Giles S, Fox S. The impact of compliance with 6-hour and 24-hour sepsis bundles on hospital mortality in patients with severe sepsis: a prospective observational study. Critical Care 2005; 9:R764-R770 Competing interests: None declared |
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Martin J Sheppard, consultant microbiologist Withybush Hospital, Pembrokeshire, SA61 2PZ
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This article leaves me with several conflicting emotions. Their exclusion criteria (skin flora unless 3 positives) makes me very worried. When a blood culture first yields Gram-positive cocci this could be skin flora or S.aureus: identification is not confirmed until the following day. It is to be hoped they did not wait until the second day before reviewing the patient! Early review often indicates when S.aureus is likely, enabling specific treatment when necessary whilst reducing inappropriate antibiotic use. The possibility of line-related bacteraemia with skin flora should also be considered: perhaps more so in a teaching hospital. This cannot be done by simply using a "3-positive" rule, as repeat cultures may not be taken without appropriate prompting by the microbiologist. As for the underlying philosophy, I am confused and depressed. Reviewing patients with bacteraemia improves management: yes. Affords opportunity for informal education (and audit): yes. But not "quality improvement"! Many microbiologists have done this for years, well back into the previous millenium: some as single-handed consultants, without the benefit of an "infection team" afforded by teaching hospital staffing levels. One wonders what they used to spend their time doing in Leeds, and what weighty matters they previously thought more important than a positive blood culture. I blush for my colleagues. Competing interests: None declared |
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Daniel G Boden, SpR Emergency Medicine New Cross Hospital, Wolverhampton
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With in-hospital mortality still quoted at up to 60% for severe sepsis this is an area which is becoming increasingly targeted by emergency physicians across the UK. Rivers et al provided the initial framework for the surviving sepsis campaign and this is being updated by a series of multi-centre worldwide trials including the Protocolized Care for Early Septic Shock (ProCESS) study in the USA and the Australasian Resuscitation in Sepsis Evaluation (ARISE) trial in Australia and New Zealand. To add to this, and of relevance to UK physicians, is the proposed Protocolised Management in Sepsis (ProMISe) trial in the UK which has been submitted as an outline proposal. This is to be conducted as a multicentre RCT looking at both the clinical factors and cost effectiveness of early protocolised care of emerging septic shock. This study promises to have the backing of the College of Emergency Medicine, the Society of Acute Medicine, the Intensive Care society and the Intensive Care National Audit and Research Centre (ICNARC). All of the aforementioned studies will hopefully bring the early treatment of sepsis to the fore in the emergency departments and MAU's across the UK. Having seen such a major push for cardiac thrombolysis and primary angioplasty over the past 10-15 years (followed by stroke thrombolysis) it seems only right that the focus should start to turn towards treatment of sepsis. As emergency physicians this is (gradually) starting to be treated as the true emergency that it should be and given both the resources and clinical care that it deserves. Competing interests: None declared |
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Figure 1. Relationship between mortality rates of patients with pneumonia
and sepsis and increasing admission lactate, antibiotic delay and fluid
resuscitation in the initial 4 hours