Does the presence of a urinary catheter predict severe sepsis in a bacteraemic cohort?
Introduction
Sepsis is a major cause of mortality with an estimated 37,000 deaths in the UK each year.1 Death can occur at any age inside and outside of hospital. The presentation of sepsis can be non-specific, and the diagnosis may be delayed or even missed. A recent UK National Confidential Enquiry into Patient Outcome and Death concluded that there was a lack of urgency in the management of severe sepsis, with only one in three patients receiving good care.2 The principal recommendations were that hospitals and primary care should have formal sepsis protocols, staff should be trained in their use, and all septic patients should receive a bundle of interventions, with senior microbiology advice available within 24 h. In 2015, National Health Service (NHS) England introduced a commissioning for quality and innovation (CQUIN) payment for NHS hospitals that met targets for screening for sepsis, taking cultures and administrating empirical antibiotics within 1 h.3
Due to delays in diagnosis and initiation of treatment, new sepsis definitions were produced nationally in 2015 to enable easier ‘out of hospital’ or bedside diagnosis.4 To optimize outcomes, a care bundle approach implemented within 1 h is required (Sepsis Six), with further actions required within 6 h if the patient is admitted to critical care.5 The National Institute of Clinical Excellence (NICE) recommends auditing outcomes in patients with severe sepsis or septic shock, not only to provide mortality data comparable to other institutions, but also to offer assurance that processes for managing sepsis are in place and working.6
Early recognition and treatment of sepsis is the key to improving outcomes. However, there are few published data on additional host factors that predict the severity of sepsis at the time of presentation, other than altered mental state, hypotension and tachypnoea.7 Early identification of factors that predict severe sepsis is important for inpatients that require management in critical care, but also for patients in the community seen before blood is taken and results made available. This study aimed to determine other patient factors that can predict severe sepsis by analysing data from a bacteraemic cohort at the Royal London Hospital (RLH) in East London, UK.
Section snippets
Study setting
This study was undertaken at the RLH, which serves a diverse population of approximately 250,000 patients in Tower Hamlets, East London. It is a regional referral centre for the North East London sector. In addition to accident and emergency, general medicine, surgery, paediatric and maternity services, the RLH has 60 high-dependency and critical care beds (including neurosurgical, renal, and obstetric and gynaecological beds), specialist wards for renal transplant and haemodialysis patients,
Results
Five hundred and ninety-four bacteraemic episodes occurred in 500 patients (Table I). Of these, 382 (64.3%) episodes were in patients aged >50 years, and 346 (58.2%) episodes were in males. Episodes were approximately distributed between community-acquired, healthcare-associated and hospital-acquired infections. Community-acquired bacteraemia was not associated with severe sepsis (Pitt score ≥2). The most common isolates were Escherichia coli and meticillin-susceptible Staphylococcus aureus,
Discussion
Following adjustment for age, sex, Charlson comorbidity index and where infection was acquired, this study demonstrated that site of infection, particularly catheter-associated UTI, was associated with severe sepsis in a bacteraemic cohort. This is an important finding as device-related infections are potentially preventable.
A strength of this study is that the Pitt score (a severity index) was used as the primary outcome rather than mortality, although both were strongly associated. At
Conflict of interest statement
None declared.
Funding sources
None.
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Cited by (19)
Validation of the Predisposition Infection Response Organ (PIRO) dysfunction score for the prognostic stratification of patients with sepsis in the Emergency Department
2021, Medicina IntensivaCitation Excerpt :This difference can be explained by the small number of cases admitted in ICU/HDU because of the seniority of our population. The main strength of our study was being prospective and following a rigorous methodology, including unselected patients with infection and considering many clinically relevant variables previously described by other authors.2,14–25 The comprehensive quality of PIRO is also its main limitation: the number of variables that requires can lead to extensively missing data and the complexity of its application doesn’t suit for emergencies.
Indwelling medical device use and sepsis risk at a health professional shortage area hospital: Possible interaction with length of hospitalization
2020, American Journal of Infection ControlCitation Excerpt :Furthermore, our findings suggest a need to focus greater efforts on improving the quality of inpatient care at HPSA hospitals in rural communities. Although the association between catheterization and sepsis risk has been described elsewhere in the literature,11,14,15,19 previous studies did not examine the possible interaction of indwelling medical device use and sepsis risk with LOS. The most frequently utilized indwelling medical device in our study population was a urinary access device.
Escherichia coli bloodstream infection outcomes and preventability: a six-month prospective observational study
2019, Journal of Hospital InfectionCitation Excerpt :Half of the cases came from a urinary source, which is consistent with larger UK studies on the epidemiology of E. coli BSI [3]. This, along with the high level of catheter use and recent urinary isolation of E. coli in the study cohort, and previous findings about the role of urinary catheters in severe sepsis [16], means that reducing catheter-associated infection is an obvious area to target. Although a study of low-dose antibiotic prophylaxis in patients intermittently self-catheterizing showed a reduction in symptomatic urinary tract infection (UTI), it did not have an effect on febrile UTI [17], which is likely to be more relevant in terms of preventing BSI.
Epidemiology and health-economic burden of urinary-catheter-associated infection in English NHS hospitals: a probabilistic modelling study
2019, Journal of Hospital InfectionCitation Excerpt :Urinary tract infection (UTI) is a leading cause of healthcare-associated infection (HCAI) and Gram-negative bloodstream infection (GNBSI) in England [1–3]. Urinary catheters (henceforth ‘catheters’) are associated with the majority of urinary HCAIs and are an important risk factor for the incidence and severity of GNBSI [4–7]. Yet catheters are often inserted without appropriate indication and left in for longer than clinically necessary [8], putting patients needlessly at risk of infection and contributing to the burden imposed by HCAI and GNBSI in England's National Health Service (NHS) [1,9].
Risk factors for sepsis morbidity in a rural hospital population: A case-control study
2018, American Journal of Infection ControlCitation Excerpt :The most prevalent devices present in the patient case population were Foley catheters (n = 49; 45%), followed by gastric or percutaneous endoscopic gastrostomy tubes (n = 23; 21%), central venous catheters (n = 19; 17%), and endotracheal tubes (n = 17; 15%). Significant associations between the presence of indwelling medical devices and sepsis have been reported previously.18-20 Indwelling devices are commonly used in health care settings for hemodynamic monitoring and delivering intravenous fluids, blood products, medications, and nutrition.
Preventing healthcare-associated Gram-negative bloodstream infections
2018, Journal of Hospital Infection