Kazım Rollas, Pervin Hancı, Kezban Ozmen Süner, Nesrin Damla Eyüpoglu, Ozgür Kılıç, Burçin Halaclı, Mehmet Nezir Güllü, Nazmiye Ebru Ersoy Ortac,

Serpil Göcmen, Arzu Topeli

Medical Intensive Care Unit, Faculty of Medicine, HacettepeUniversity, Ankara, Turkey

INTRODUCTION Even in the developed countries, the frequency of

sepsis is increasing.

Sepsis is the most common cause of death in non-coronary intensive care units (*).

There is not enough data available concerning the epidemiology of sepsis in our country.

* Angus DC, Linde-Zwirble WT, Lidicker J, Clermont G, Carcillo J, Pinsky MR. Epidemiology of severe sepsis in the United States: analysis of incidence, outcome, and associated costs of care. Crit Care Med 2001; 29:1303-10

OBJECTIVE

We aimed to investigate the frequency and general characteristics of the severe sepsis and septic shockpatients in our unit.

METHOD The records of all patients admitted to the medical ICU of

Hacettepe university hospital between 1st January 2007 and

31st December 2014 were retrospectively reviewed from

unit’s database and hospital electronic records. Severe

sepsis and septic shock patients were included

Data are presented as number of cases (%) and median

(minimum–maximum).

RESULTS Over the 8 year period, 1507 patients were admitted to

ICU.

Of those,104 patients who had less than 24 hours of hospitalization were excluded.

464 (33.1%) of 1403 patients were admitted to ICU withsevere sepsis and septic shock.

224 (48.3 %) patients died in the ICU.

269 (58 %) patients died during the hospital stay.

Mean expected mortality rate adjusted for APACHE II score was 48.1%.

Totaln=464

Nonsurvivorn=224

Survivorn=240

P value

Age 64 (17-95) 64 (18-92) 65 (17-95) 0.55

Sex (male/female) 258/206 (55.6) 131/93 (58.5) 127/113 ( 52.9) 0.26

APACHE II 23 (5-59) 27 (7-59) 20 (5-52) <0.01

SOFA 9 (2-20) 11 (3-20) 8 (2-20) <0.01

Number of organ failure 3 (1-6) 3 (1-6) 3 (1-6) <0.01

Lactate (mmol/L) 2.1 (0.2-16) 2.4 (0.3-14.3) 1.7 (0.2-16) <0.01

Charlson comorbidity index 4 (0-15) 4 (0-15) 3.5 (0-13) 0.02

ComorbiditiesCardiac diseases 182 (39.2) 89 (39.7) 93 (38.7) 0.91

Diabetes mellitus 103 (22.2) 42 (18.8) 61 (25.4) 0.09

Chronic respiratory failure 98 (21.1) 40 (17.9) 58 (24.2) 0.11

Solid cancers 93 (20.0) 51(222.8) 42(17.5) 0.16

Chronic renal failure 85 (18.3) 43 (19.2) 42 (17.5) 0.71

Hematologic cancers 45 (9.7) 31 (13.8) 14 (5.8) <0.01

Neurological diseases 43 (9.3) 20 (8.9) 23 (9.6) 0.87

Hematological diseases 20 (4.3) 12 (5.4) 8 (3.3) 0.36

Rheumatological diseases 17 (3.4) 4 (1.8) 13 (5) 0.07

Chronic liver failure 15 (3.2) 10 (4.5) 5 (2.1) 0.19

Length of stay in ICU (day) 8 (2-189) 8 (2-182) 9 (2-189) 0.03

Length of stay in hospital (day) 23 (2-189) 17.5 (2-182) 29 (3-89) 0.01

Totaln=464

Nonsurvivorn=224

Survivorn=240

P value

Procalcitonin (mg/L) 3.1 (0.02-468) 4.05(0.04-468) 2.17 (0.02-351) <0.01

C-reaktive protein (mg/L)

12.6 (0.08-69.1) 13.4 (0.13-69.1) 12.1 (0.08-69) 0.24

Vasopressors 294/456 (64.5) 172/222 (77.5) 122 /234 (52.1) <0.01

Inotropes 80/391 ( 20.5) 50/187 (26.7) 30/204 (14.7) <0.01

Steroids 271/453 (36.8) 150/221 (67.9) 121/232(52.2) <0.01

Red blood celltransfusion

225/456 (49.3) 131/220 (59.5) 94/236 ( 39.8) <0.01

Invasive mechanicalventilation

291/460 (63.3) 162/222 (73) 129/238(54.2) <0.01

Noninvasive mechanicalventilation

118/460 (25.4) 64/222 (28.8) 54/ 238 (22.7) 0.13

Hemodialysis 156/458(34.1) 87/222 ( 39.2) 69/236(29.2) 0.03

Suspected Sepsis/Infection Source

Totaln=464

Nonsurvivorn=224

Survivorn=240

P value

Respiratory 211 (45.5) 100 (4.6) 111 (46.3) 0.78

Urinary 40 (8.6) 13 (5.8) 27 (11.3) 0.04

Blood stream 37 (8.0) 22 (9.8) 15 (6.3) 0.17

Intraabdominal 22 (5.0) 10 (4.5) 12 (5.0) 0.83

Skin- soft tissue 20 (4.3) 9 (4.0) 11 (4.6) 0.82

Unknown source 134 ( 28.9) 70 (26.7) 64 (31.3) 0.30

50,6 % of patients had positive microbial isolates

Site of infection

Totaln=464

Nonsurvivorn=224

Survivorn=240

P value

Respiratory 89 (37.9) 55 (45.1) 34 (30.1) 0.02

Bloodstream 75 (31.9) 38 (31.1) 37 (32.7) 0.88

Urinary tract 51 (21.7) 20 (16.4) 31 (27.4) 0.05

Wound /softtissue

11 (4.7) 5 (4.1) 6(5,3) 0.76

Others 9 (3.8) 4 (3.3) 5 (4.4) 0.74

Isolated microorganismsTotaln=235 (%)

Nonsurvivorn=122 (%)

Survivorn=113 (%)

P value

Escherichia coli spp. 54 (23) 22 (18) 32 (28.3) 0.06

Candida spp. 38 (16.2) 23 (18.9) 15 (13.3) 0.28

Acinetobacter spp. 37 (15.7) 18 (14) 19(16.8) 0.72

Enterococcus spp. 22(9.4) 20 (16.4) 9 (8) 0.07

Staphylococcus aureus 23 (8.9) 11 (9.0) 12 (10.6) 0.82

Pseudomonas spp. 19 (8.1) 11 (9.0) 8 (7.1) 0.63

Klebsiella spp. 19 (8.1) 13 (10.7) 6 (5.3) 0.15

Staphylococcus epidermidis 7 ( 3.0) 2 (1.6) 5 (4.4) 0.26

Staphylococcus haemalyticus

7 (3) 4 (4.3) 3 (2.7)

Streptococcus pneumoniae 5 (2.1) 3 (2.5) 2 (1.8)

Stenotrophomonas maltophilia

5 (2.1) 4 (3.3) 1 (0.9) 0.37

Aspergillus spp. 4 (1.7) 3 (2.5) 1 (0.9) 0.62

Others 33(14.0) 18 (14.8) 15 (13.3) 0.85

Polimicrobial 42 (17.9) 25 (20.5) 17 (15) 0.3

The frequency and mortality rates of severe sepsis and septic shock patients over the years

33,5

37,5

21,3

37,9 38,536,3 35,7

24,5

55,5

43,4

37,8

53,4

48,346,7

50,8 51

58,4

52,1 51,3

63,1

57,659,6 60,6

65,3

0

10

20

30

40

50

60

70

2007APACHE II26 (11-48)

2008APACHE II28 (10-52)

2009APACHE II26 (9-59)

2010APACHE II26(10-46)

2011APACHE II

18 (7-34)

2012APACHE II20 (5-44)

2013APACHE II

19 (8-43)

2014APACHE II24 (10-43)

The frequency of severe sepsis andseptic shock

Mortality in ICU

Mortality in hospital

The frequency is lower in 2009 and 2014 ( respectively p <0.01 and p<0,01) p = 0.87 for ICU mortality over the yearsp= 0.14 for hospital mortality over the years

DISCUSSION

Frequency of severe sepsis/ septic shock was 33 % in our unit’s large patient sample.

Frequency of severe sepsis was detected as 30% forEuropean Intensive Care Units by Vincent et al (SOAP trial).

Vincent JL, Sakr Y, Sprung CL, Reinhart MR, et al. Sepsis in European Intensive Care Units: Result of the

SOAP Study. Crit Care Med, 2006; 34: 344-353

Mortality of patients with severe sepsis and septicshock was found as 48.3 % in our intensive care unit.

In SOAP trial, mortality of severe sepsis and septicshock was 32% and 54 % respectively

The most common cause of sepsis was respiratory tract(37.9 %), and the most frequent isolated agents weregram negative microorganisms.

The most common cause of sepsis was found as respiratory tract (40 %), and the most common agentwas found as gram negative bacterias by Mayr et al.

Mayr FB, Yende S, Linde-Zwirble WT, Peck-Palmer OM, Barnato AE, Weissfeld LA, Angus DC. Infection rate and acute organ dysfunction risk as explanations for racial differences in severe sepsis. JAMA. 2010;303:2495–503.

In our unit, there was differences in the frequency of sepsis over the 8 years but significant change was not observed in ICU and hospital mortality.

CONCLUSION Severe sepsis/ septic shock remains a common disease

with high mortality in ICU.

In our counrty, there is a need for prospective multi-

center studies about sepsis epidemiology.