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Expected and observed mortality in critically ill patients receiving initial antibiotic therapy

Erwartete und beobachtete Mortalität kritisch kranker Patienten mit initialer antiinfektiver Therapie

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Summary

Objective

To evaluate the predictors of mortality in critically ill patients receiving initial antibiotic therapy (IAT; < 48 h after admission).

Methods

Six hundred thirty-one consecutive patients admitted to an intermediate care (IMC) unit were included. IAT was initiated in 227 patients. Laboratory markers, interventions, medications, systemic inflammatory response syndrome (SIRS) and sepsis criteria, length of stay, and hospital mortality as well as expected mortality, based on the SAPSII-expanded score, were assessed retrospectively. Failure of IAT was defined as a rise in C-reactive protein (CRP) or leukocyte count on day 3 compared with the values on admission.

Results

Patients with IAT were significantly older (67 ± 14 vs. 64 ± 14 years; p = 0.006) and had a higher prevalence of chronic renal failure (33 vs. 23 %; p = 0.015), chronic obstructive pulmonary disease (COPD; 27 vs. 16 %; p = 0.002), malignoma (17 vs. 9 %; p = 0.007), acute renal failure (11 vs. 4 %; p = 0.001), respiratory failure (22 vs. 7 %; p < 0.001), and a shock index < 1.0 (21 vs. 8 %; p < 0.001). Although patients with IAT did not have significantly different expected mortality compared with patients without IAT (19.2 vs. 14.5 %; p = 0.144), they did have a significantly higher observed mortality (16.7 vs. 3.7 %; p < 0.0001). Based on the number of SIRS criteria (0, 1, 2, or 3–4) or sepsis criteria (no sepsis, sepsis, or severe sepsis) fulfilled, expected mortality (16.4, 18.2, 20.6, or 21.0 %, respectively; p = 0.955/17.5, 18.3, or 23.4 %, respectively; p = 0.689) did not differ in IAT patients. In contrast, observed mortality differed significantly (4.8, 10.6, 20.6, or 29.4 %, respectively; p = 0.029/8.3, 19.7, or 29.3 %, respectively; p = 0.013). Patients who responded to IAT did not differ regarding comorbidities, SIRS or sepsis criteria, but they had a lower observed mortality (11.9 vs. 26.3 %; p = 0.008) than patients who failed to respond to IAT. Central venous lines were more frequently present in patients with failure to IAT when compared with those with response (51 vs. 22 %; p = 0.009). In the subgroup of patients with acute myocardial infarction (AMI), those with IAT (n = 41) were treated less frequently according to the current cardiac guidelines than those without (n = 124)

Conclusions

Patients with IAT have a high morbidity burden and higher observed than expected mortality. The SAPSII-expanded score does not seem to precisely estimate the risk of in-hospital mortality in these patients. Failure of response to IAT was associated with an even higher mortality. Whether central venous lines and nonadherence to cardiac care guidelines influence the mortality of patients with IAT should be investigated in further studies.

Zusammenfassung

Zielsetzung

Evaluation von Mortalitätsprediktoren bei kritisch kranken Patienten mit initialer antiinfektiver Therapie (IAT) (< 48 h nach stationärer Aufnahme).

Methodik

Sechshunderteinunddreißig Patienten, die aufeinander folgend auf eine Intermediate Care Station aufgenommen wurden, wurden in die Studie eingeschlossen.

Eine initiale antiinfektive Therapie (IAT) wurde bei 227 Patienten begonnen. Laborwerte, Interventionen, Medikationen, SIRS und Sepiskriterien, Dauer des Aufenthaltes und die Mortalität während des Krankenhausaufenthaltes ebenso wie die nach SAPS II Score erwartete Mortalität, wurden retrospektiv erfasst.

Bei einem Anstieg von C-reaktiven Protein (CRP) oder Leukozyten am 3. Tag nach Aufnahme, verglichen mit den Werten vom Aufnahmetag, wurde ein Versagen der initialen antiinfektiven Therapie angenommen.

Ergebnisse

Patienten, welche eine IAT erhielten, waren signifikant älter (67 ± 14 vs. 64 ± 14 Jahre; p = 0,006) und hatten eine höhere Prävalenz von chronischer Niereninsuffizienz (33 vs. 23 %; p = 0,015), COPD (27 vs. 16 %; p = 0,002), Malignomen (17 vs. 9 %; p = 0,007), akutem Nierenversagen (11 vs. 4 %; p = 0,001), respiratorischer Insuffizienz (22 vs. 7 %; p = 0,001) und hämodynamischen Schock (21 vs. 8 %; p = 0,001). Obwohl Patienten mit IAT keine signifikant unterschiedliche erwartete Mortalität (SAPS-II-EXPANDED) im Vergleich zu Patienten ohne IAT hatten (19,2 vs. 14,5 %; p = 0,144), hatten die Patienten mit IAT eine signifikant erhöhte beobachtete Mortalität (16,7 vs. 3,7 %;p = 0,0001). Die beobachtete Mortalität divergierte signifikant nach Anzahl der erfülltem SIRS-Kriterien (0, 1, 2 oder 3–4) (4,8, 10,6, 20,6 bzw. 29.4 %; p = 0.029) bzw. Sepsis-Kategorien (keine Sepsis, Sepsis, schwere Sepsis) (8,3, 19,7 bzw. 29,3 %; p = 0.013), während sich die erwartete Mortalität in diesen Gruppen nach SAPS-II-Expanded nicht wesentlich unterschied (16,4, 18,2, 20,6 bzw. 21,0 %, p = 0,955/ 17,5, 18,3 bzw. 23,4 %; p = 0,689). Patienten, die auf die initiale antiinfektive Therapie ansprachen, unterschieden sich nicht in Bezug auf Komorbititäten, SIRS oder Sepsiskriterien, hatten aber eine niedrigere beobachtete Mortalität (11,9 vs. 26,3 %; p = 0,008) als die Patienten, bei denen die IAT versagte. Patienten, bei denen die IAT versagte, hatte häufiger Zentrale Venenkatheter als Patienten, welche auf die IAT ansprachen (51 vs. 22 %; 0,009). In der Subgruppe der Patienten mit akuten Myokardinfarkt wurden die Patienten, welche eine IAT erhielten (n = 41) weniger häufig nach den aktuellen kardiologischen Leitlinien behandelt, als die Patienten, welche keine IAT erhielten (n = 124).

Schlussfolgerungen

Patienten mit initialer antiinfektiver Therapie haben eine höhere Morbidität und die beobachtete Mortalität ist höher als die Erwartete. Die Krankenhausmortalität dieser Patienten wird vom SAPS-II-expanded-Score nicht präzise vorhergesagt, während einfache Sepsis-Parameter eine gewisse Vorhersagekraft haben. Ein Versagen der IAT war mit einer nochmals erhöhten Mortalität assoziiert. Ob Zentrale Venenkatheter oder die nicht-Einhaltung der kardiologischen Leitlinien Einfluß auf die Mortalität hat, sollte in weiteren Studien untersucht werden.

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Abbreviations

IAT:

= Initial (< 48 h after admission) antibiotic therapy

SAPSII:

= Simplified Acute Physiology Score II (Intensive care score to predict mortality)

CRP:

= C-reactive protein (inflammatory marker)

SIRS:

= Systemic inflammatory response syndrome

COPD:

= Chronic obstructive pulmonary disease

CAD:

= Coronary artery disease

AMI:

= Acute myocardial infarction

ACE:

= Angiotensin-converting enzyme

TRT:

= Troponin T

NIV:

= Noninvasive ventilation

GIB:

= Gastrointestinal bleeding

IMC:

= Intermediate care

SOP:

= Standard operating procedure

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The authors declare that there is no actual or potential conflict of interest in relation to this article.

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Correspondence to Thorsten Janisch MD.

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Janisch, T., Wendt, J., Hoffmann, R. et al. Expected and observed mortality in critically ill patients receiving initial antibiotic therapy. Wien Klin Wochenschr 124, 775–781 (2012). https://doi.org/10.1007/s00508-012-0276-0

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  • DOI: https://doi.org/10.1007/s00508-012-0276-0

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