Incidence, trends, and outcomes of infection sites among hospitalizations of sepsis: A nationwide study

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Abstract

Purpose

To determine the trends of infection sites and outcome of sepsis using a national population-based database.

Materials and methods

Using the Nationwide Inpatient Sample database of the US, adult sepsis hospitalizations and infection sites were identified using a validated approach that selects admissions with explicit ICD-9-CM codes for sepsis and diagnosis/procedure codes for acute organ dysfunctions. The primary outcome was the trend of incidence and in-hospital mortality of specific infection sites in sepsis patients. The secondary outcome was the impact of specific infection sites on in-hospital mortality.

Results

During the 9-year period, we identified 7,860,687 admissions of adult sepsis. Genitourinary tract infection (36.7%), lower respiratory tract infection (36.6%), and systemic fungal infection (9.2%) were the leading three sites of infection in patients with sepsis. Intra-abdominal infection (30.7%), lower respiratory tract infection (27.7%), and biliary tract infection (25.5%) were associated with highest mortality rate. The incidences of all sites of infections were trending upward. Musculoskeletal infection (annual increase: 34.2%) and skin and skin structure infection (annual increase: 23.0%) had the steepest increase. Mortality from all sites of infection has decreased significantly (trend p<0.001). Skin and skin structure infection had the fastest declining rate (annual decrease: 5.5%) followed by primary bacteremia (annual decrease: 5.3%) and catheter related bloodstream infection (annual decrease: 4.8%).

Conclusions

The anatomic site of infection does have a differential impact on the mortality of septic patients. Intra-abdominal infection, lower respiratory tract infection, and biliary tract infection are associated with higher mortality in septic patients.

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Most cited references 23

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Benchmarking the incidence and mortality of severe sepsis in the United States.

David F Gaieski, J. Edwards, Michael Kallan … (2013)

In 1992, the first consensus definition of severe sepsis was published. Subsequent epidemiologic estimates were collected using administrative data, but ongoing discrepancies in the definition of severe sepsis produced large differences in estimates. We seek to describe the variations in incidence and mortality of severe sepsis in the United States using four methods of database abstraction. We hypothesized that different methodologies of capturing cases of severe sepsis would result in disparate estimates of incidence and mortality. Using a nationally representative sample, four previously published methods (Angus et al, Martin et al, Dombrovskiy et al, and Wang et al) were used to gather cases of severe sepsis over a 6-year period (2004-2009). In addition, the use of new International Statistical Classification of Diseases, 9th Edition (ICD-9), sepsis codes was compared with previous methods. Annual national incidence and in-hospital mortality of severe sepsis. The average annual incidence varied by as much as 3.5-fold depending on method used and ranged from 894,013 (300/100,000 population) to 3,110,630 (1,031/100,000) using the methods of Dombrovskiy et al and Wang et al, respectively. Average annual increase in the incidence of severe sepsis was similar (13.0% to 13.3%) across all methods. In-hospital mortality ranged from 14.7% to 29.9% using abstraction methods of Wang et al and Dombrovskiy et al. Using all methods, there was a decrease in in-hospital mortality across the 6-year period (35.2% to 25.6% [Dombrovskiy et al] and 17.8% to 12.1% [Wang et al]). Use of ICD-9 sepsis codes more than doubled over the 6-year period (158,722 - 489,632 [995.92 severe sepsis], 131,719 - 303,615 [785.52 septic shock]). There is substantial variability in incidence and mortality of severe sepsis depending on the method of database abstraction used. A uniform, consistent method is needed for use in national registries to facilitate accurate assessment of clinical interventions and outcome comparisons between hospitals and regions.

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Rapid increase in hospitalization and mortality rates for severe sepsis in the United States: a trend analysis from 1993 to 2003.

Viktor Y Dombrovskiy, Andrew Martin, Jagadeeshan Sunderram … (2007)

To determine recent trends in rates of hospitalization, mortality, and hospital case fatality for severe sepsis in the United States. Trend analysis for the period from 1993 to 2003. U.S. community hospitals from the Nationwide Inpatient Sample that is a 20% stratified sample of all U.S. community hospitals. Subjects of any age with sepsis including severe sepsis who were hospitalized in the United States during the study period. None. Utilizing International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes for septicemia and major organ dysfunction, we identified 8,403,766 patients with sepsis, including 2,857,476 patients with severe sepsis, who were hospitalized in the United States from 1993 to 2003. The percentage of severe sepsis cases among all sepsis cases increased continuously from 25.6% in 1993 to 43.8% in 2003 (p < .001). Age-adjusted rate of hospitalization for severe sepsis grew from 66.8 +/- 0.16 to 132.0 +/- 0.21 per 100,000 population (p < .001). Age-adjusted, population-based mortality rate within these years increased from 30.3 +/- 0.11 to 49.7 +/- 0.13 per 100,000 population (p < .001), whereas hospital case fatality rate fell from 45.8% +/- 0.17% to 37.8% +/- 0.10% (p < .001). During each study year, the rates of hospitalization, mortality, and case fatality increased with age. Hospitalization and mortality rates in males exceeded those in females, but case fatality rate was greater in females. From 1993 to 2003, age-adjusted rates for severe sepsis hospitalization and mortality increased annually by 8.2% (p < .001) and 5.6% (p < .001), respectively, whereas case fatality rate decreased by 1.4% (p < .001). The rate of severe sepsis hospitalization almost doubled during the 11-yr period studied and is considerably greater than has been previously predicted. Mortality from severe sepsis also increased significantly. However, case fatality rates decreased during the same study period.

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Hospitalizations, costs, and outcomes of severe sepsis in the United States 2003 to 2007.

Tara Lagu, Michael Rothberg, Meng-Shiou Shieh … (2012)

To assess trends in number of hospitalizations, outcomes, and costs of severe sepsis in the United States. Temporal trends study using the Nationwide Inpatient Sample. Adult patients with severe sepsis (defined as a diagnosis of sepsis and organ dysfunction) diagnosed between 2003 and 2007. We determined the weighted frequency of patients hospitalized with severe sepsis. We calculated age- and sex-adjusted population-based mortality rates for severe sepsis per 100,000 population and also used logistic regression to adjust in-hospital mortality rates for patient characteristics. We calculated inflation-adjusted costs using hospital-specific cost-to-charge ratios. We identified a rapid steady increase in the number of cases of severe sepsis, from 415,280 in 2003 to 711,736 in 2007 (a 71% increase). The total hospital costs for all patients with severe sepsis increased from $15.4 billion in 2003 to $24.3 billion in 2007 (57% increase). The proportion of patients with severe sepsis and only a single organ dysfunction decreased from 51% in 2003 to 45% in 2007 (p < .001), whereas the proportion of patients with three or four or more organ dysfunctions increased 1.19-fold and 1.51-fold, respectively (p < .001). During the same time period, we observed 2% decrease per year in hospital mortality for patients with severe sepsis (p < .001), as well as a slight decrease in the length of stay (9.9 days to 9.2 days; p < .001) and a significant decrease in the geometric mean cost per case of severe sepsis ($20,210 per case in 2003 and $19,330 in 2007; p = .025). The increase in the number of hospitalizations for severe sepsis coupled with declining in-hospital mortality and declining geometric mean cost per case may reflect improvements in care or increases in discharges to skilled nursing facilities; however, these findings more likely represent changes in documentation and hospital coding practices that could bias efforts to conduct national surveillance.

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Author and article information

Contributors

Eric H. Chou: Role: ResourcesRole: SupervisionRole: Writing – review & editing

Shaynna Mann: Role: Writing – original draftRole: Writing – review & editing

Tzu-Chun Hsu: Role: Methodology

Wan-Ting Hsu: Role: Data curationRole: Formal analysisRole: Methodology

Carolyn Chia-Yu Liu: Role: Methodology

Toral Bhakta: Role: Writing – review & editing

Dahlia M. Hassani: Role: Writing – review & editing

Chien-Chang Lee:

ORCID: http://orcid.org/0000-0002-1243-2463

Role: ConceptualizationRole: Data curationRole: Formal analysisRole: MethodologyRole: Project administrationRole: ResourcesRole: SupervisionRole: Writing – review & editing

Florian B. Mayr: Role: Editor

Journal

Journal ID (nlm-ta): PLoS One

Journal ID (iso-abbrev): PLoS ONE

Journal ID (publisher-id): plos

Journal ID (pmc): plosone

Title: PLoS ONE

Publisher: Public Library of Science (San Francisco, CA USA )

ISSN (Electronic): 1932-6203

Publication date (Electronic): 13 January 2020

Publication date Collection: 2020

Volume: 15

Issue: 1

Electronic Location Identifier: e0227752

Affiliations

[1 ] Department of Emergency Medicine, John Peter Smith Hospital, Fort Worth, Texas, United States of America

[2 ] Department of Emergency Medicine, Baylor Scott and White All Saints Medical Center, Fort Worth, Texas, United States of America

[3 ] Department of Emergency Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan

[4 ] Department of Epidemiology, Harvard T. H. Chan School of Public Health, Boston, Massachusetts, United States of America

[5 ] McTimoney College of Chiropractic, School of Health, BPP University, Abingdon, Oxfordshire, United Kingdom

University of Pittsburgh, UNITED STATES

Author notes

Competing Interests: The authors have declared that no competing interests exist.

[¤]

Current address: Department of Emergency Medicine, National Taiwan University Hospital, Taipei, Taiwan

* E-mail: cclee100@ 123456gmail.com

Author information

Chien-Chang Lee http://orcid.org/0000-0002-1243-2463

Article

Publisher ID: PONE-D-19-15923

DOI: 10.1371/journal.pone.0227752

PMC ID: 6957188

PubMed ID: 31929577

SO-VID: fe7fce8c-ed47-4a2b-98a5-9a31f0d17a1b

License:

This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

History

Date received : 5 June 2019

Date accepted : 27 December 2019

Page count

Figures: 4, Tables: 3, Pages: 13

Funding

The author(s) received no specific funding for this work.

Custom metadata

Data Availability All relevant data are within the manuscript and its Supporting Information files.

Incidence, trends, and outcomes of infection sites among hospitalizations of sepsis: A nationwide study

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Abstract

Purpose

Materials and methods

Results

Conclusions

Related collections

Decoding Infection and Transmission

Most cited references 23

Benchmarking the incidence and mortality of severe sepsis in the United States.

Rapid increase in hospitalization and mortality rates for severe sepsis in the United States: a trend analysis from 1993 to 2003.

Hospitalizations, costs, and outcomes of severe sepsis in the United States 2003 to 2007.

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