Does the presence of a urinary catheter predict severe sepsis in a bacteraemic cohort?

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Summary

Background

Sepsis is a major cause of mortality with an estimated 37,000 deaths in the UK each year. This study aimed to determine host factors that can predict severe sepsis in a bacteraemic cohort.

Methods

From December 2012 to November 2013, demographic, clinical and microbiological data were collected on consecutive patients with bacteraemia at a London teaching hospital. These data were used to categorize patients as having severe or non-severe sepsis. Multi-variate logistic regression was used to determine the association between host factors and severe sepsis.

Findings

Five hundred and ninety-four bacteraemic episodes occurred in 500 patients. The majority of cases were in patients aged >50 years (382/594, 64.3%) and in males (346/594, 58.2%). The most common isolates were Escherichia coli (207/594, 34.8%) and meticillin-susceptible Staphylococcus aureus (57/594, 9.6%). In logistic regression multi-variable analysis, site of infection was significantly associated with severe sepsis. For catheter-associated urinary tract infections, the association was significant after adjustment for age, sex, Charlson comorbidity index and where infection was acquired (odds ratio 3.94, 95% confidence interval 1.70–9.11).

Conclusions

Urinary catheters increase the risk of severe sepsis. They should only be used if clinically indicated. If inserted, a care bundle approach should be used and the anticipated removal date should be recorded unless a long-term catheter is required. In the context of sepsis, the presence of a urinary catheter should prompt immediate implementation of ‘Sepsis Six’ and consideration of transfer to a critical care unit.

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.

References (19)

There are more references available in the full text version of this article.

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