Septik şok ön tanılı olgularda ampirik tedavi başlanma zamanının klinik gidişe etkisinin retrospektif olarak değerlendirilmesi
Küçük Resim Yok
Dosyalar
Tarih
2021
Yazarlar
Dergi Başlığı
Dergi ISSN
Cilt Başlığı
Yayıncı
Ege Üniversitesi, Tıp Fakültesi
Erişim Hakkı
info:eu-repo/semantics/openAccess
Özet
Amaç: Çalışmanın birincil amacı, Sepsis-3 kriterlerine göre septik şok (SŞ) ön tanılı olgularda ampirik tedavi başlanma zamanının klinik gidişe etkisinin belirlenmesiydi. İkincil amaç ise, ampirik tedavinin etkenleri kapsama oranının bir aylık mortalite üzerine etkisinin değerlendirilmesiydi. Gereç ve Yöntem: Çalışmaya Mart 2016 – Mart 2021 arasında Ege Üniversitesi Hastanesi Acil Servis ve diğer yataklı birimlerinde yatarak tedavi gören, tez öğrencisi ve/veya tez danışmanı tarafından değerlendirilen, Sepsis-3 kriterlerine göre SŞ ön tanılı 18 yaşından büyük hastalar dahil edildi. Birinci ay sağkalım, tek değişkenli analizler ile değerlendirildi. Tek değişkenli analizde istatistiksel olarak anlamlı sonuç saptanan parametreler lojistik regresyon analizi ile değerlendirildi. Bulgular: Çalışmada, dahil edilme kriterlerine uyan 204 hasta [ortalama yaş 64,5 ± 15,7 (18-117) %37,2 kadın] değerlendirildi. Hastaların %31,3'üne (n=64) SŞ tanısı Acil Servis'te konuldu. En sık enfeksiyon odağı pnömoni (%71,5), üriner sistem enfeksiyonu (%26,4) ve bakteremi-fungemi (%20,5) idi. Mikrobiyolojik etken olguların %50'sinde izole edildi. En sık mikroorganizmalar %21,5 Staphylococcus spp., %19,6 Klebsiella spp., %17,6 Acinetobacter spp. ve %16,6 maya mantarlarıydı. Ampirik tedavinin etkeni kapsama oranı %76,4'tü. Ampirik tedavinin etkeni kapsadığı ve kapsamadığı hastalar arasında birinci ay mortalite açısından anlamlı fark yoktu (p=0,851). Tek değişkenli analizde birinci ay sağkalımı etkileyen bağımsız risk faktörleri; birinci saatte antibiyotik başlanması (21/54-%38,9 karşı 34/150-%22,7 p=0,021), SŞ tanısı konulan birim (Acil Servis 8/64-%12,5 karşı yataklı birim 47/140-%33,5 p=0,001), SŞ tanısı konulduğu esnadaki SOFA (SOFA<11 33/70-%47,1 karşı SOFA≥11 22/134-%19,1 p=0,00007) ve qSOFA skorları (qSOFA 2 27/58-%46,5 karşı qSOFA 3 28/146-%16,4 p=0,000002) ile arteryel kan gazındaki laktat değeri (laktat 2-4 mmol/L 38/100-%38 karşı laktat≥4 mmol/L 17/104-%16,3 p=0,000049) olarak bulundu. Çok değişkenli analizde ise Acil Servis'te SŞ tanısı konulması (p = 0,005, olasılıklar oranı (OO) = 3,8, %95 GA [güven aralığı] = 1,4-9,6), SOFA skorunun ≥11 olması (p = 0,003, OO = 3,1, %95 GA = 1,4-6,5), qSOFA skorunun üç olması (p = 0,02, OO = 2,5, %95 GA = 1,1-5,4) ve arteryel kan gazında laktat değerinin ≥4 mmol/L olması (p = 0,027, OO = 2,2, %95 GA = 1-4,6) birinci ay mortalite ile ilişkili saptandı. Sonuç: Çalışmamız bildiğimiz kadarıyla Sepsis-3 kriterlerine göre SŞ alt kümesindeki mortaliteyi etkileyen faktörlerin incelendiği ve vazopresör başlandıktan sonra antimikrobiyal tedavi başlanma süresi ile mortalite arasındaki ilişkiyi araştıran Türkiye'deki ilk, Dünya'daki sayılı çalışmalardandır. Acil Servis ve hastanenin tüm birimlerinde SŞ tanı ve tedavi farkındalığının artırılmasına yönelik eğitim programları oluşturulup, erken tanıya ve konsültasyon istenmesine yönelik elektronik hasta dosyasında ek uyarıcı sistemler oluşturulmalıdır. SŞ tanısı konduktan sonra bir saat içinde antibiyotik başlanabilme oranları artırılmalıdır.
Aim: The main goal of this study was to determine the impact of the timing empirical antimicrobial therapy on the clinical progress of patients with the preliminary diagnosis of septic shock (SS) patients (diagnosed according to Sepsis-3 criteria). Secondary goal was to analyze the effect of empirical therapy coverage on one-month mortality. Materials and Method: Adult (>18 years old) patients, who had preliminary diagnosis of SS according to Sepsis-3 criteria and hospitalized in the Ege University Hospital Department of Emergency Service and other inpatient units between March 2016 to March 2021 and who had been evaluated by the thesis student and/or thesis advisor, were included in the study. The one-month survival was evaluated with univariate analysis. Afterwards, the parameters with statistically significant results in univariate analysis were evaluated with logistic regression analysis. Results: A total of 204 patients [mean age 64.5 ± 15.7 (18-117) 37.2% women), who met the inclusion criteria, were included in the study. The SS was diagnosed in the Department of Emergency Service in 31.3% (n=64) of the patients. The most common infection sites were pneumonia (71.5%) followed by urinary tract infection (26.4%) and bacteremia-fungemia (20,5%). Microbiological etiology was elucidated in 50% cases. The most common pathogens were 21.5% Staphylococcus spp, 19.6% Klebsiella spp 17.6% Acinetobacter spp and 16.6% yeasts. Rate of empirical therapy coverage on etiological agents was 76.4%. There was no statistically significant difference in terms of one-month mortality between patients in whom empirical therapy covered and did not cover the etiologic agent (p=0.851). In univariate analysis independent predictive factors that significantly affected one-month survival were; starting antibiotics at the first hour (21/54-38.9% vs. 34/150-22.7% p=0.021), the unit where the case was diagnosed with SS (Emergency Service 8/64-12.5% vs. other clinics 47/140-33.5% p=0.001), SOFA scores (SOFA<11 33/70-47.1% vs. SOFA≥11 22/134-19.1% p=0.00007) and qSOFA scores (qSOFA 2 27/58-46,5% vs. qSOFA 3 28/146-16.4% p=0.000002), and lactate value in arterial blood gas (lactate 2-4 mg/dl 38/100-38% versus lactate≥4 17/104-16.3% p=0 .000049). The following variables were significantly associated with one-month mortality in multivariate analysis; diagnosis of SS in the Emergency Service (p=0.005, OR=3.8, 95%CI [confidence interval] 1.4-9.6), SOFA score ≥11 (p=0.003, OR=3.1, 95% CI= 1.4-6.5), qSOFA score of three (p=0.02, OR= 2.5, 95% CI = 1.1-5.4) and lactate value in arterial blood gas between ≥4 (p=0.027, OR=2.2, 95% CI = 1-4.6). Conclusion: To our knowledge this is the first study in Turkey and one of the few studies in the world that analyse the factors affecting mortality in the SS subgroup diagnosed with Sepsis-3 criteria and investigating the relationship between the timing of antimicrobial therapy after starting vasopressor and mortality. Training programs should be designed to increase the awareness of SS diagnosis and treatment in the Emergency Service as well as all units of the hospital. Furthermore, additional warning systems should be created in the electronic patient file for earlier diagnosis and consultation. The rate of starting antibiotics within one hour after the diagnosis of SS should be increased.
Aim: The main goal of this study was to determine the impact of the timing empirical antimicrobial therapy on the clinical progress of patients with the preliminary diagnosis of septic shock (SS) patients (diagnosed according to Sepsis-3 criteria). Secondary goal was to analyze the effect of empirical therapy coverage on one-month mortality. Materials and Method: Adult (>18 years old) patients, who had preliminary diagnosis of SS according to Sepsis-3 criteria and hospitalized in the Ege University Hospital Department of Emergency Service and other inpatient units between March 2016 to March 2021 and who had been evaluated by the thesis student and/or thesis advisor, were included in the study. The one-month survival was evaluated with univariate analysis. Afterwards, the parameters with statistically significant results in univariate analysis were evaluated with logistic regression analysis. Results: A total of 204 patients [mean age 64.5 ± 15.7 (18-117) 37.2% women), who met the inclusion criteria, were included in the study. The SS was diagnosed in the Department of Emergency Service in 31.3% (n=64) of the patients. The most common infection sites were pneumonia (71.5%) followed by urinary tract infection (26.4%) and bacteremia-fungemia (20,5%). Microbiological etiology was elucidated in 50% cases. The most common pathogens were 21.5% Staphylococcus spp, 19.6% Klebsiella spp 17.6% Acinetobacter spp and 16.6% yeasts. Rate of empirical therapy coverage on etiological agents was 76.4%. There was no statistically significant difference in terms of one-month mortality between patients in whom empirical therapy covered and did not cover the etiologic agent (p=0.851). In univariate analysis independent predictive factors that significantly affected one-month survival were; starting antibiotics at the first hour (21/54-38.9% vs. 34/150-22.7% p=0.021), the unit where the case was diagnosed with SS (Emergency Service 8/64-12.5% vs. other clinics 47/140-33.5% p=0.001), SOFA scores (SOFA<11 33/70-47.1% vs. SOFA≥11 22/134-19.1% p=0.00007) and qSOFA scores (qSOFA 2 27/58-46,5% vs. qSOFA 3 28/146-16.4% p=0.000002), and lactate value in arterial blood gas (lactate 2-4 mg/dl 38/100-38% versus lactate≥4 17/104-16.3% p=0 .000049). The following variables were significantly associated with one-month mortality in multivariate analysis; diagnosis of SS in the Emergency Service (p=0.005, OR=3.8, 95%CI [confidence interval] 1.4-9.6), SOFA score ≥11 (p=0.003, OR=3.1, 95% CI= 1.4-6.5), qSOFA score of three (p=0.02, OR= 2.5, 95% CI = 1.1-5.4) and lactate value in arterial blood gas between ≥4 (p=0.027, OR=2.2, 95% CI = 1-4.6). Conclusion: To our knowledge this is the first study in Turkey and one of the few studies in the world that analyse the factors affecting mortality in the SS subgroup diagnosed with Sepsis-3 criteria and investigating the relationship between the timing of antimicrobial therapy after starting vasopressor and mortality. Training programs should be designed to increase the awareness of SS diagnosis and treatment in the Emergency Service as well as all units of the hospital. Furthermore, additional warning systems should be created in the electronic patient file for earlier diagnosis and consultation. The rate of starting antibiotics within one hour after the diagnosis of SS should be increased.
Açıklama
Anahtar Kelimeler
Septik Şok, Ampirik Tedavi, Tedavi Başlama Zamanı, Bir Aylık Mortalite, Septic Shock, Empirical Therapy, Timing of Therapy, One-Month Mortality
