Early ID Consultation Reduces Sepsis-Related Mortality

Severe sepsis and septic shock are leading causes of morbidity and mortality in US hospitals, but early severe sepsis and septic shock treatment bundles have been shown to improve clinical outcomes.

In a new study, experts from the Albert Einstein College of Medicine and Princeton University sought to evaluate the impact of a prompt consultation from an infectious diseases (ID) specialist on clinical outcomes and antimicrobial prescribing among sepsis patients.

Their research, published in Open Forum Infectious Diseases, demonstrates that patients who received an early treatment bundle and a consultation with an ID specialist within 12 hours of admission had a 40% risk reduction for in-hospital mortality.

The study focused on a collaborative Emergency Department-Infectious Diseases team care program that was implemented at the Einstein campus at Montefiore Medical Center to improve sepsis-related outcomes. Only patients who received the 3-hour sepsis treatment bundle were included in the retrospective analysis. This consisted of 248 adult patients. The investigators compared 111 patients who received an ID consult within 12 hours of admission (early ID group) with 137 patients who did not receive a prompt ID consult (standard-of-care group).

According to the results the in-hospital mortality was lower in the ED triage group unadjusted (24.3% vs 38.0%, P = .02) and adjusted for covariates (odds ratio, 0.47; 95% confidence interval (CI), 0.25—0.89; P = .02). Additionally, there was no significant difference observed in 30-day readmission (22.6% vs 23.5%, P = .89) or median LOS (10.2 vs 12.1 days, P = .15) among patients who survived their illness.

“Early ID consultation was protective of in-hospital mortality (adjusted subdistribution hazard ratio (asHR), 0.60; 95% CI 0.36—1.00, P = .0497) and predictive of discharge alive (asHR 1.58, 95% CI, 1.11—2.23; P-value .01) after adjustment,” the article states.

The study authors explained that the mortality difference is not attributable to the 3-hour sepsis bundle, as all patients included in the study received the bundle. “The observed difference in mortality also cannot be attributed to antibiotic appropriateness, antibiotic effectiveness, or pathogen identification in our study as these outcomes were not significantly different between groups,” the authors wrote in their report.

Investigators did see a potential difference, however, between groups. They noted “a statistical trend toward shorter time to antibiotic de-escalation in the early ID group compared with the standard care group and shorter duration of antibiotic therapy…compared to later ID consult in the subsample where an antibiotic duration recommendation was made, but neither reached statistical significance (possibly due to small sample size).”

Study author Theresa Madaline, MD, assistant professor of medicine at Albert Einstein College of Medicine and Health Care Epidemiologist at Montefiore Health System, told Contagion® that "stopping antibiotics sooner, or de-escalation, after an appropriate number of treatment days has been shown in multiple studies to be beneficial. It is hypothesized that reduction in adverse effects from prolonged antibiotics, such as kidney injury, Clostridium difficile, etc. might be the reason that shorter courses or transition from very broad spectrum antibiotics to a more narrow spectrum regimen improves clinical outcomes. We also speculate that the multidisciplinary collaboration, team-based care, and shared decision making in the infectious diseases-emergency department program also contributes to positive outcomes through changes in clinical decision making."

Based on these findings, the study team suggests that future studies should explore the impact of collaborative team care and de-escalation of treatment among this patient population. Madaline said that the study "adds to a rapidly growing body of literature demonstrating improved outcomes and shorter time to de-escalation of antibiotics for people with sepsis or other infectious conditions when an infectious diseases specialist is part of the care team," and that "infectious diseases physicians are incredibly valuable members of the care team, and are experts at antibiotic management. The involvement of infectious diseases physicians in every sepsis case, when possible, should be considered to optimize prescribing and to drive optimal outcomes."