Early infectious disease consultation may reduce mortality in sepsis

An infectious disease (ID) consultation within 12 hours of presenting to the emergency department (ED) with severe sepsis and septic shock (SS/SS) may lower mortality risk, a recent retrospective study showed.

“[H]aving an ID physician as part of the team of doctors that cares for [a patient with serious infection, including sepsis] will probably result in better outcomes,” said study lead author Assistant Professor Theresa Madaline from the Albert Einstein College of Medicine, Montefiore Medical Center, New York, US.

Study participants were 248 adults (mean age 71.4 years, 51.6 percent female) with SS/SS who completed a 3-hour sepsis bundle* in the ED of the Einstein campus of the Montefiore Medical Center. The researchers compared outcomes between patients who had an ID consult within 12 hours of ID triage (early ID; median time to consult, 2 hours; n=111) and those without ID consult within 12 hours (standard of care [SoC]; n=137). In the SoC group, 54.7 percent underwent ID consult later in the clinical course of initial ED admission (median time to consult, 27 hours).

In-hospital mortality occurred less frequently among patients who had an early ID consult than those treated with SoC (24.3 percent vs 38.0 percent; adjusted odds ratio [adjOR], 0.47, 95 percent confidence interval [CI], 0.25–0.89; p=0.02). Age (adjOR, 1.03; p=0.01) and use of vasopressors within 72 hours (adjOR, 2.76; p=0.003) were associated with a higher risk of in-hospital mortality. [Open Forum Infect Dis 2019;6:ofz408]

Among patients who survived the index hospitalization, readmission to hospital at 30 days occurred at a comparable rate between early ID consult and SoC recipients (22.6 percent vs 23.5 percent; p=0.89). Median duration of hospitalization (10.2 vs 12.1 days; p=0.15) and median duration of antibiotic therapy (7.0 vs 9.0 days; p=0.72) also did not significantly differ between the early ID and SoC groups.

There was no significant difference between the early ID and SoC groups with regard to appropriate antibiotic prescriptions (82.0 percent vs 81.0 percent; p=0.85), effective antibiotic prescriptions (99.1 percent vs 99.3 percent; p=1.00), de-escalation of antibiotic therapy (64.9 percent vs 58.4 percent; p=0.30), or confirmed infection diagnosis (82.0 percent vs 81.0 percent; p=0.85).

Early ID consultation had a protective effect against in-hospital mortality (adjusted subdistribution hazard ratio [adjsHR], 0.60, 95 percent CI, 0.36–1.00; p=0.0497), with patients who had an early ID consult having a better likelihood of surviving to discharge (adjsHR, 1.58, 95 percent CI, 1.11–2.23; p=0.01).

Conversely, vasopressor use was associated with a lower likelihood of surviving to discharge (adjsHR, 0.48; p=0.0001) and was linked to higher risk of mortality (adjsHR, 2.26; p=0.002), with similar outcomes noted for age (adjsHR, 0.99; p=0.008 and adjsHR, 1.02; p=0.02, respectively).

“Our study adds to the mounting evidence that ID consultation as part of a team-based care approach is associated with improved patient outcomes, and addition of ID consultation to sepsis bundles should be considered,” said the researchers.

As the inclusion criteria was limited to only patients who completed the 3-hour sepsis bundle, the reduction in mortality rates with early ID consultation could not be attributed to compliance to the bundle, nor could it be explained by receipt of appropriate or effective antibiotic therapy, as these outcomes did not differ between groups, they noted. As such, further research is warranted to identify the reasons behind the mortality benefit with early ID consultation.

“It is important to continue to pursue research on how ID specialists can best partner with other providers to optimize patient outcomes, and how early consultation models can be tailored in different environments. Diagnosing and treating severe sepsis can be a huge challenge, so it is important to remember that there is ‘no one size fits all’ model for improving outcomes for people impacted by this condition,” said Madaline.