VOL . 7 ISSUE 2 ● FEBRUARY 2025 By Ed Septimus , MD
EDITOR ’ S CHOICE
Electronic Sepsis
01 Screening Among Patients Admitted to Hospital Wards : A Stepped-Wedge Cluster Randomized Trial
Clinical Outcomes
04 of Early Phenotype-Desirable Antimicrobial Therapy for Enterobacterales Bacteremia
07 Effectiveness
of Ceftazidime – Avibactam vs . Ceftolozane Tazobactam for Multidrug-resistant Pseudomonas aeruginosa Infections in the U . S . ( CACTUS ): A Multicenter , Retrospective , Observational Study
Updates on the
09 Treatment of Drug- Susceptible and Drug- Resistant Tuberculosis An Official ATS / CDC / ERS / IDSA Clinical Practice Guideline
Highly Pathogenic
18 Avian Influenza A ( H5N1 ) Virus
Antiviral Medications
21 for Treatment of Nonsevere Influenza : A Systematic Review and Network Meta-Analysis
EDITOR ’ S CHOICE
Electronic Sepsis Screening Among Patients Admitted to Hospital Wards : A Stepped-Wedge Cluster Randomized Trial
JAMA . Published online Dec . 10 , 2024 doi : 10.1001 / jama . 2024.25982
The purpose of this study was to evaluate the effect of an electronic sepsis screening tool , compared with no screening , on mortality among hospitalized ward patients . They used a stepped-wedge , cluster randomized trial at 5 hospitals , 45 wards ( clusters ) which were randomized into 9 sequences , 5 wards each , to have sepsis screening implemented at 2-month periods . An electronic alert , based on the quick Sequential Organ Failure Assessment ( qSOFA ) score , was implemented in the electronic medical record in a silent mode that was activated to a revealed mode for sepsis screening . In the study wards , blood pressure and respiratory rate values were entered into the EMR every 4 hours and the Glasgow Coma Scale score every 12 hours . The EMR generated an alert on each vital sign input if 2 or more of the qSOFA components ( systolic blood pressure ≤100 mm Hg , respiratory rate ≥22 breaths / min , or Glasgow Coma Scale score < 15 ) were met within a 12-hour window based on the recent values .
After a baseline period of 2 months in which the alert was in silent mode in all wards , the alert was activated to revealed mode in a new sequence every 2 months until the alert became active in all wards . The alerts appeared in the EMR as pop-up messages for the nurse and physician , accompanied by a visual and audible alarm on a handheld device carried by the ward charge nurse . The alert prompted the nurse to acknowledge the alert , assess the patient , and communicate with the covering physician . It prompted the physician to acknowledge the alert by documenting an assessment of whether the patient had sepsis or not . The acknowledgments were time-stamped . Dashboards and monthly reports were used for feedback and displayed the number of alerts and the percentage and timing of acknowledgment by nurses and physicians for feedback .
The primary outcome was 90-day in-hospital mortality . There were 11 secondary outcomes , including code blue activation , vasopressor therapy , incident kidney replacement therapy , multidrugresistant organisms , and Clostridioides difficile ( CDI ).
Among 60,055 patients , 29,442 were in the screening group and 30,613 in the no screening group . They had a median age of 59 years ( IQR , 39-68 ), and 51 % were males . Alerts occurred in 4299 of 29,442 patients ( 14.6 %) in the screening group and 5394 of 30,613 ( 17.6 %) in the no screening group . Within 12 hours of the alert , patients in the screening group were more likely to have serum lactate tested ( adjusted relative risk [ aRR ], 1.30 ; 95 % CI , 1.16-1.45 ) and intravenous fluid ordered ( aRR , 2.17 ; 95 % CI , 1.92-2.46 ) compared with those in the no screening group . In the primary outcome analysis , electronic screening resulted in lower 90- day in-hospital mortality ( aRR , 0.85 ; 95 % CI , 0.77-0.93 ; P < . 001 ).
Screening reduced vasopressor therapy and multidrug-resistant organisms but increased code blue activation , incident kidney replacement therapy , and CDI . As the Covid-19 pandemic started after trial launch , the baseline mortality increased in later periods corresponding with Covid-19 waves , resulting in 2-fold more Covid-19 cases and higher risk patients in the screening group compared with the no screening group . This confounding was accounted for by adjusting for periods and Covid-19 status . Subgroup analysis demonstrated that screening was similarly effective in patients without or with Covid-19 and across study periods .
DR . SEPTIMUS ’ S ANNOTATIONS
Accounting for period , clustering within wards , hospitals , and Covid-19 status , electronic sepsis screening significantly reduced in-hospital mortality within 90 days compared with no screening
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