Background
Methods
Design and setting
Participants
Data collection
Data definitions
Analysis
Results
Characteristics | Number (%) of ICUs | Number (%) of patients |
---|---|---|
59 | 1184 | |
Facility | ||
Type of ICU | ||
Open | 36 (61.0) | 594 (50.2) |
Closed | 23 (39.0) | 590 (49.8) |
ICU specialty | ||
Medical | 3 (5.1) | 78 (6.6) |
Mixed | 56 (94.9) | 1106 (93.4) |
Number of ICU beds | ||
1–10 | 25 (42.4) | 363 (30.7) |
11–20 | 26 (44.1) | 580 (50.0) |
≥ 21 | 8 (13.6) | 241 (20.4) |
Number of hospital beds | ||
≤ 500 | 13 (22.0) | 185 (15.6) |
501–900 | 31 (52.5) | 637 (53.8) |
≥ 901 | 15 (25.4) | 362 (30.6) |
Type of hospital | ||
Non-university | 30 (50.8) | 458 (38.7) |
University | 29 (49.2) | 726 (61.3) |
Staff | ||
Number of board-certificated intensivists | ||
0 | 14 (23.7) | 211 (17.8) |
1 | 16 (27.1) | 243 (20.5) |
≥ 2 | 29 (49.2) | 730 (61.7) |
Number of board certificated emergency physicians | ||
0–4 | 17 (28.8) | 167 (14.1) |
5–8 | 22 (37.3) | 321 (27.1) |
≥ 9 | 20 (33.9) | 696 (58.8) |
Number of ICU nurses | ||
≤ 40 | 29 (49.2) | 584 (49.3) |
> 40 | 30 (50.8) | 600 (50.7) |
Nurse to bed ratio in each shift | ||
1:2 | 50 (84.7) | 1052 (88.9) |
1:4 | 9 (15.3) | 132 (11.1) |
Patients | ||
Number of emergency patients (2014) (n = 50) | ||
≤ 4000 | 14 (28.0)) | 293 (28.8) |
4001–18,000 | 23 (46.0) | 509 (50.0) |
≥18,001 | 13 (26.0) | 216 (21.2) |
Number of ambulance patients (2014) (n = 50) | ||
≤ 2000 | 15 (30.0) | 313 (30.7) |
2001–5000 | 20 (40.0) | 295 (29.0) |
≥ 5001 | 15 (30.0) | 410 (40.3) |
Number of ICU patients (2013) (n = 58) | ||
≤ 500 | 15 (25.9) | 216 (18.2) |
501–1000 | 28 (48.3) | 642 (54.2) |
≥ 1001 | 15 (25.9) | 326 (27.5) |
Characteristics | |
---|---|
Age at admission, years | 73 (64–81) |
Male | 719/1184 (60.7) |
BMI, kg/m2 | 22 (19–25) |
Admission source | |
ED | 676 (57.2) |
non-ED (hospital/department transfers) | 457 (38.7) |
ICU | 49 (4.1) |
Coexisting conditions | |
Myocardial infarction | 58 (4.9) |
Congestive heart failure | 128 (10.8) |
Peripheral vascular disease | 29 (2.4) |
Cerebrovascular disease | 140 (11.8) |
Dementia | 97 (8.2) |
COPD | 82 (6.9) |
Connective tissue disease | 83 (7.0) |
Peptic ulcer disease | 32 (2.7) |
Diabetes mellitus without organ damage | 197 (16.6) |
Diabetes mellitus with organ damage | 75 (6.3) |
Chronic kidney disease | 85 (7.2) |
Hemiplegia | 44 (3.7) |
Malignancy (solid) | 161 (13.6) |
Malignancy (blood) | 23 (1.9) |
Metastatic tumor | 26 (2.2) |
Mild liver disease | 46 (3.9) |
Moderate to severe liver disease | 26 (2.2) |
AIDS | 1 (0.1) |
CCI | |
0 | 391 (33.0) |
1–2 | 542 (45.8) |
3–4 | 182 (15.4) |
> 4 | 69 (5.8) |
ADL | |
Dependent | 288 (24.3) |
Suspected site of infection | |
Lung | 367 (31.0) |
Abdomen | 311 (26.3) |
Urinary tract | 218 (18.4) |
Soft tissue | 117 (9.9) |
Central nervous system | 23 (1.9) |
IV catheter | 22 (1.9) |
Osteoarticular | 21 (1.8) |
Endocardium | 16 (1.4) |
Wound | 12 (1.0) |
Implant device | 8 (0.7) |
Other | 69 (5.8) |
Positive blood cultures | 636 (54.0) |
Septic shock | |
Yes | 745 (62.9) |
Organ dysfunction on arrival | |
Hypotension | 656 (55.4) |
Hyperlactatemia (> 2 mmol/L) | 797 (67.3) |
Acute kidney injury (Cre > 2 mg/dL) | 455 (38.4) |
Acute lung injury | 442 (37.3) |
Hyperbilirubinemia (> 2.0 mg/dL) | 204 (17.2) |
Thrombocytopenia (< 100,000/μL) | 345 (29.1) |
Coagulopathy (INR > 1.5) | 225 (19.0) |
ARDSa at 1st day | 193 (18.0) |
qSOFA score | 2 (1–3) |
qSOFA ≥ 2 | 800 (69.6) |
APACHE II score | 23 (17–29) |
SIRS score | 3 (2–4) |
SOFA score | 9 (6–11) |
SOFA score ≥ 2 | 987 (98.6) |
Microbiological results of blood cultures | n = 560 |
Gram-negative | |
E. coli | 182 (32.5) |
Klebsiella | 72 (12.9) |
Pseudomonas | 16 (2.9) |
Gram-positive | |
Staphylococci | 91 (16.3) |
Streptococci | 109 (19.5) |
MRSA | 16 (2.9) |
Enterococcus | 25 (4.5) |
Anaerobic | 24 (4.3) |
Fungi | 14 (2.5) |
Antibiotics | n = 1140 |
Penicillin derivative (PCG, ABPC, ABPC/MCIPC) | 30 (2.6) |
Ampicillin/sulbactam | 78 (6.8) |
PIPC/TAZ | 238 (20.9) |
Sulbactam/cefoperazone | 11 (1.0) |
First-generation cephalosporin | 28 (2.5) |
Second-generation cephalosporin (CTM, CMZ, FMOX) | 32 (2.8) |
Third-generation cephalosporin (CTX, CPZ, CTRX) | 99 (8.7) |
Third-generation cephalosporin against pseudomonas | 4 (0.4) |
Fourth generation cephalosporin against pseudomonas | 26 (2.3) |
Carbapenem | 627 (55.0) |
Aminoglycoside | 8 (0.7) |
Quinolone | 19 (1.7) |
Tetracycline | 7 (0.6) |
Macrolide | – |
Metronidazole | 12 (1.1) |
CLDM | 48 (4.2) |
Vancomycin | 203 (17.8) |
Other anti-methicillin-resistant Staphylococcus aureus drugs | 67 (5.9) |
Antifungals | 50 (4.4) |
Others | 83 (7.3) |
Compliance rate | |
---|---|
Compliance with all applicable elements of sepsis 3-h bundle | |
Entire 3-h resuscitation bundlea | 543/844 (64.3) |
B1. Serum lactate obtained | 1143/1180 (96.9) |
B2. Broad-spectrum antibiotic given | 985/1179 (83.5) |
B3. Blood cultures obtained before broad-spectrum antibiotic administration | 1084/1178 (92.0) |
B4. 30 mg/kg crystalloid fluid bolus delivered (yes/cases with indication)a | 645/845 (76.3) |
Compliance with all applicable elements of sepsis 6-h bundle | |
Entire 6-h resuscitation bundleb | 41/688 (3.5) |
Vasopressors use + re-measured lactate | 625/752 (83.1) |
B5. Vasopressor use followed initial fluid bolus if needed to maintain MAP ≥ 65 mmHg (yes/cases with indication) | 745/841 (88.6) |
B6. CVP measured (yes/cases with indication)a | 225/856 (26.3) |
B7. CVP 8 mmHg achieved (yes/cases with indication)a | 181/227 (79.7) |
B8. ScvO2 measured (yes/cases with indication)a | 60/853 (7.0) |
B9. ScvO2 70% (or SvO2 65%) achieved (yes/cases with indication)a | 49/66 (74.2) |
B10. Re-measured lactate if initial lactate elevated (yes/cases with indication) | 864/960 (90.0) |
Entire 3-h resuscitation bundle + vasopressors use + re-measured lactate | 397/693 (57.3) |
Entire 3-h resuscitation bundle + vasopressors use | 449/750 (59.9) |
Characteristics | Odds_(95%CI) |
---|---|
Type of ICU | |
Closed | 2.84_(1.28–6.28) |
Number of ICU beds | |
1–10 | |
11 to 20 | 0.88_(0.38–2.08) |
≥ 21 | 1.57_(0.44–5.6) |
Type of hospital | |
University | 0.35_(0.15–0.78) |
Number of board-certified intensivists | |
0 | |
1 | 0.7_(0.25–1.95) |
≥ 2 | 0.62_(0.24–1.64) |
ICU nurse ratio | |
1:2 | 1.24_(0.41–3.75) |
Number of ICU patients per year | |
0–500 | |
501–1000 | 1.22_(0.48–3.14) |
≥ 1001 | 2.18_(0.61–7.78) |
Outcomes | |
---|---|
In-hospital mortality | 269/1148 (23.4 (21.0–26.0)%) |
with shock (n = 745) | 200/718 (27.9 (24.6–31.3)%) |
Survivor disposition | |
Home | 323/879 (36.7) |
Transfer | 556/879 (63.3) |
ICU-free days | 19 (11–24) |
Ventilator-free days | 21 (0–28) |
Length of hospital stay | 24 (12–46) |
Characteristics | Odds_(95%CI) |
---|---|
Age at admission, years | 1.02_(1.01–1.04) |
Male sex | 0.81_(0.57–1.14) |
Body mass index | 1_(0.97–1.04) |
ADL | 0.88_(0.58–1.32) |
Admission source | |
ED | reference |
w/o ED (transfer or other department) | 1.12_(0.78–1.62) |
ICU | 1.99_(0.91–4.36) |
CCI | 1.2_(1.09–1.32) |
Septic shock | |
Yes | 1.01_(0.63–1.62) |
Suspected site of infection | |
Lung | reference |
Abdomen | 0.54_(0.35–0.85) |
Urinary tract | 0.22_(0.12–0.41) |
Soft tissue | 0.73_(0.4–1.33) |
Others | 1.16_(0.7–1.89) |
SOFA score | 1.18_(1.12–1.24) |
Positivity of blood cultures (bacteremia) | 1.16_(0.82–1.64) |
Fluid resuscitation protocola | |
Not achievement | reference |
Achievement | 1.14_(0.72–1.82) |
Not indicated | 1.06_(0.59–1.91) |
Broad-spectrum antibiotic use | 1.04_(0.66–1.64) |
Discussion
Summary
Limitations
Conclusions
Key messages
-
Patients with severe sepsis in Japan were super-elderly with comorbidities, with in-hospital mortality comparable to other developed countries.
-
Sepsis management in Japan was characterized by a high compliance with the 3-h bundle and low compliance with the CVC measurement in the 6-h bundle.
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Mortality continued to increase even after an acute phase of severe sepsis, although one third of survivors were discharged to their homes after recovery.