Helping Prevent Sepsis-Related Deaths With Appropriate Antibiotics

According to recent findings published online in JAMA Network Open, sepsis is a leading cause of death in US hospitals.  

In order to estimate the prevalence, underlying causes, and preventability of sepsis-associated mortality within hospitals, a group of researchers, led by Chanu Rhee, MD, MPH, intensivist and infectious disease physician at Brigham and Women’s Hospital and an assistant professor in the Department of Population Medicine at Harvard Medical School, and colleagues, conducted a cohort study. Dr Rhee and colleagues reviewed medical records of 568 randomly selected adults admitted to 6 US academic and community hospitals from January 1, 2014, to December 31, 2015. The patients died in the hospital or were discharged to hospice and not readmitted.

According to the findings, sepsis was present in 300 hospitalizations and directly caused death in 198 cases. The researchers noted that most underlying causes of death were related to severe chronic comorbidities and only 3.7% of sepsis-associated deaths were judged definitely or moderately preventable. 

To help understand the findings of the study as well as discuss why a pharmacist plays an important role in sepsis care, Pharmacy Learning Network spoke with Dr Rhee.  

Please tell us a little about yourself.

I am an intensivist and infectious disease physician at Brigham and Women’s Hospital and an Assistant Professor in the Department of Population Medicine at Harvard Medical School.  My clinical and research interest is the epidemiology, surveillance, diagnosis, prevention, and treatment of sepsis and infectious in critically ill patients. 

Briefly discuss the prevalence of sepsis-related deaths within US hospitals.

We studied the prevalence of sepsis-related deaths by conducting detailed medical record reviews of 568 patients who died during their hospitalization in six different academic and community hospitals around the U.S. We also examined patients discharged to hospice, since this is an increasingly common end of life destination.  We found that over half of the patients who died or were discharged to hospice had sepsis at some point during their hospitalization.  In most of these cases, sepsis directly led to death. 

How did the number of sepsis-related deaths compare to other causes of death?

Sepsis was by far the most common immediate cause of death, as it directly caused death in 35% of all patients who died.  The next most common immediate causes of death were progressive cancer (16% of cases) and heart failure (7%).    

What can be done to lower the number of sepsis-related deaths?

We found that up to 1 in 8 sepsis deaths were potentially preventable with better hospital-based care. This suggests that while ongoing efforts to improve sepsis recognition and care in the hospital are successful in many cases, there is still room to improve since our goal is to get to 0 preventable deaths.  However, our findings also suggest that to really have a major impact on sepsis mortality we need to look outside the hospital and focus on better prevention and management of the conditions that predispose patients to sepsis, such as cancer, heart and lung disease, and other chronic illnesses.  Faster recognition of sepsis in the outpatient setting and expeditious referral to the hospital could likely help reduce sepsis-related deaths as well. 

What role can a pharmacist play, if any, to help address the number of sepsis-related deaths?

In the inpatient setting, pharmacists play an important role in sepsis care by ensuring patients receive appropriate doses of antibiotics and that the spectrum of antibiotics is right for any isolated pathogens. Pharmacists can also help by pointing out opportunities for treating clinicians to de-escalate antibiotics after the initial 48-72 hours.   On a hospital systems level, pharmacists are also key in ensuring that the right processes are in place so that antibiotics can be rapidly delivered for patients with sepsis.   

Were you surprised by the study findings?

I wasn’t completely surprised.  In my own experience as a critical care physician, a lot of sepsis patients we treat in the hospital are extremely sick and even when they receive timely and optimal medical care, many do not survive.   

Is there anything else you would like to add?

The fact that many sepsis deaths are probably not preventable with better hospital-based care should not diminish the tragedy of having even one preventable death from sepsis or the importance of ongoing efforts in hospitals across the nation to improve sepsis recognition and management.  However, our study might help set realistic expectations around what can be currently achieved with hospital-based care, and suggests that further improvement and innovations in the prevention and care of underlying conditions may be necessary before we can see further major reduction in sepsis deaths.

One limitation is that we only included 6 hospitals from 3 U.S. regions, including 3 major academic centers, all of which are generally considered to be high quality hospitals.  The extent to which our findings are true in hospitals with less resources, or hospitals that have not made sepsis care a priority, is unclear, so it would be important to replicate these findings in different sets of hospitals.

This research was funded by the CDC Prevention Epicenters Program, and in part by the Agency for Healthcare Research and Quality.