Likelihood of infection in patients with presumed sepsis at the time of intensive care unit admission: a cohort study

Peter M C Klein Klouwenberg, Olaf L Cremer, Lonneke A van Vught, David S Y Ong, Jos F Frencken, Marcus J Schultz, Marc J Bonten, Tom van der Poll, Peter M C Klein Klouwenberg, Olaf L Cremer, Lonneke A van Vught, David S Y Ong, Jos F Frencken, Marcus J Schultz, Marc J Bonten, Tom van der Poll

Abstract

Introduction: A clinical suspicion of infection is mandatory for diagnosing sepsis in patients with a systemic inflammatory response syndrome. Yet, the accuracy of categorizing critically ill patients presenting to the intensive care unit (ICU) as being infected or not is unknown. We therefore assessed the likelihood of infection in patients who were treated for sepsis upon admission to the ICU, and quantified the association between plausibility of infection and mortality.

Methods: We studied a cohort of critically ill patients admitted with clinically suspected sepsis to two tertiary ICUs in the Netherlands between January 2011 and December 2013. The likelihood of infection was categorized as none, possible, probable or definite by post-hoc assessment. We used multivariable competing risks survival analyses to determine the association of the plausibility of infection with mortality.

Results: Among 2579 patients treated for sepsis, 13% had a post-hoc infection likelihood of "none", and an additional 30% of only "possible". These percentages were largely similar for different suspected sites of infection. In crude analyses, the likelihood of infection was associated with increased length of stay and complications. In multivariable analysis, patients with an unlikely infection had a higher mortality rate compared to patients with a definite infection (subdistribution hazard ratio 1.23; 95% confidence interval 1.03-1.49).

Conclusions: This study is the first prospective analysis to show that the clinical diagnosis of sepsis upon ICU admission corresponds poorly with the presence of infection on post-hoc assessment. A higher likelihood of infection does not adversely influence outcome in this population.

Trial registration: ClinicalTrials.gov NCT01905033. Registered 11 July 2013.

Figures

Fig. 1
Fig. 1
Plausibility of infection stratified by clinical severity upon presentation in patients with presumed sepsis. Comparison between the clinical diagnosis of infection at the time of ICU admission and the actual presence of infection as determined by post-hoc evaluation
Fig. 2
Fig. 2
Plausibility of infection in patients with presumed sepsis upon presentation for the most frequent sites of infection. Distribution of plausibility of infection for lung infections (community-acquired pneumonia and hospital-acquired pneumonia), abdominal infections (primary and secondary peritonitis), bloodstream infections (primary bloodstream infections, catheter-related bloodstream infections, and endocarditis), urinary tract infections, and skin/soft tissue infections
Fig. 3
Fig. 3
Patient outcomes for various sites of infection stratified by plausibility of infection. Data are crude associations. The length of ICU stay (LoS) is shown as median. ICU-acquired infections (ICU-AI) were defined as infections that started >48 hours after admission with a plausibility of infection of at least possible. Acute kidney injury (AKI) and adult respiratory distress syndrome (ARDS) that were present at or occurred during ICU admission were taken into account. Whiskers indicate the 95 % CI. p values indicate the results of the Cochran-Armitage chi-square test for trend. Urinary tract and skin/soft tissue infections are not shown because of relatively small subgroups after stratification
Fig. 4
Fig. 4
Crude and adjusted cumulative incidence functions of mortality stratified by plausibility of infection. The adjusted curve (right) was plotted by imputing average values of age, gender, cardiovascular disease, immunocompromised state, malignancy, diabetes mellitus, respiratory insufficiency, renal insufficiency, recent surgery, sepsis severity, site of infection, and APACHE IV score into the model

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