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RBTI ORIGINAL ARTICLE

2008:20:2:128-134

Sepsis in the Intensive Care Unit: Etiologies,
Prognostic Factors and Mortality*
Sepse na Unidade de Terapia Intensiva: Etiologias,
Fatores Prognósticos e Mortalidade
Fernando Zanon1; Jairo José Caovilla2; Regina Schwerz Michel3; Estevan Vieira Cabeda3;
Diego Francisco Ceretta3; Graziela Denardin Luckemeyer4; Cássia Beltrame4; Naiana Posenatto4

SUMMARY developed SIRS (58%). The most frequent cause of in-
ternation was neurological disease (28.9%), the most fre-
BACKGROUND AND OBJECTIVES: Sepsis is the main quent site of infection was the respiratory tract (71.6%),
cause of death in patients treated in intensive care units and the most prevalent pathogens were gram-negative
(ICU). The aim of this study was to evaluate etiology, bacilli (53.2%). Mean APACHE II score was 18 ± 9, and
prognostic factors and mortality of septic patients treated mean SOFA score was 5 ± 4. Median ICU stay was 6
in ICU of Passo Fundo, Brazil. (3-11) days and overall mortality rate was 31.1%: 6.1%
METHODS: Out of 971 consecutive patients prospecti- for non-infectious SIRS, 10.1% for sepsis, 22.6% for se-
vely evaluated from August 2005 to February 2006, 560 vere sepsis, and 64.8% for septic shock.
were selected due to presence of systemic inflammatory CONCLUSIONS: Sepsis is an important health problem
response syndrome (SIRS) and followed for 28 days or that leads to an extremely high mortality rate in the ICU of
until discharge or death. Patients were categorized ac- Passo Fundo, Brazil.
cording with the etiology of SIRS and further classified Key Words: epidemiology, sepsis, septic shock, severe
as having SIRS, sepsis, severe sepsis and septic shock. sepsis, systemic inflammatory response syndrome.
Prognosis was assessed by means of APACHE II and
SOFA. Mortality was compared in different etiologies of RESUMO
sepsis, APACHE II and SOFA scores, parameters.
RESULTS: Of the 971 patients admitted to the ICU, 560 JUSTIFICATIVA E OBJETIVOS: Sepse é a principal
causa de morte em pacientes tratados em unidade
1. Specialist in Intensive Care, Associação de Medicina Intensiva de terapia intensiva (UTI). O objetivo deste estudo foi
Brasileira. avaliar etiologia, fatores prognósticos e mortalidade de
2. Professor, Medical Clinics, Universidade de Passo Fundo.
pacientes sépticos tratados nas UTI de Passo Fundo,
3. Resident, Department of Medical Clinics, Hospital da Cidade de
Passo Fundo. Brasil.
4. Resident, Department of Medical Clinics, Hospital São Vicente de MÉTODO: Foram avaliados 971 pacientes consecuti-
Paulo, Passo Fundo. vos prospectivamente, entre agosto de 2005 e feverei-
*Received from Hospital da Cidade de Passo Fundo (HCPF), Hospital ro de 2006, 560 foram selecionados pela presença de
Prontoclínica (HP) and Hospital São Vicente de Paulo (HSVP), Passo síndrome da resposta inflamatória sistêmica (SIRS) e
Fundo, RS acompanhados por 28 dias ou até a alta ou óbito. Os
Presented in February 19, 2008
pacientes foram classificados de acordo com a etiolo-
Accepted for publication in April 13, 2008 gia da SIRS e adicionalmente classificados como tendo
SIRS, sepse, sepse grave e choque séptico. O prog-
Address for correspondence:
nóstico foi avaliado por meio dos escores APACHE II
Fernando Zanon, M.D.
Rua Paissandu, 488/402 - Centro e SOFA. A mortalidade foi comparada em diferentes
99010-101 Passo Fundo, RS, Brazil etiologias de sepse e parâmetros APACHE II e SOFA.
Phone: +55-54-30457217 RESULTADOS: Dos 971 pacientes admitidos nas UTI,
E-mail: zanoncti@hotmail.com
560 desenvolveram SIRS (58%). A causa mais fre-
©Associação de Medicina Intensiva Brasileira, 2008 qüente de internação foi doença neurológica (28.9%),

128 Revista Brasileira de Terapia Intensiva
Vol. 20 Nº 2, Abril/Junho, 2008

but. bruary 2006. 750 million admissions in the US in 22 years. whose 64. immunosuppression. Demographic data. O dy included patients at the time of diagnosis of SIRS tempo médio de permanência foi 6 (3-11) dias e a taxa (time zero). Patients could change from one severity stage to the tals in Passo Fundo. ICU studied are located in three hospitals: Hospital da Unitermos: choque séptico. a ciosa. In 2001. This study was approved by the Ethics 1990. They have from 90 to 550 hospital beds. Angus et al. ICU length of stay. increase because of population ageing. severe sepsis. SEPSIS IN THE INTENSIVE CARE UNIT: ETIOLOGIES. and septic shock. Brazil. and found mor. with a mortality rate of 28. Another study conducted in Brazil analyzed II scores were calculated in the first 24 hours of hos- data from 75 ICU in different regions. death. epidemiologia.1% para sepse.1% para SIRS não infec. 20 Nº 2. Brasil. síndrome da resposta inflamatória sistêmica (HP) and Hospital São Vicente de Paulo (HSVP). other. found sion in the study. PROGNOSTIC FACTORS AND MORTALITY o mais freqüente local de infecção foi o trato respira.2% in mission. sep. the American College of Chest Physicians and the So- This study evaluated epidemiologic data and mortality ciety of Critical Care Medicine (ACCP/SCCM) in 199117. rates of patients with sepsis in the ICU of three hospi. 10.5 studied over six and developed systemic inflammatory response syn- million records of hospital discharges in seven states in drome (SIRS)17 while in the ICU. the neighboring state of Santa Catarina. Each severe sepsis per year. therefo- Revista Brasileira de Terapia Intensiva 129 Vol.7/100000 inhabitants in 2000. and this trend is were classified according to 4 stages: non-infectious expected to accelerate in the future5. the Center for Disease Control and Prevention in Research Committee of UPF. where Passo Fundo is located. APACHE shock12. 22. O escore APACHE II This prospective multicenter observational cohort stu- médio foi 18 ± 9 e o escore SOFA médio foi 5 ± 4. and two of them are INTRODUCTION university hospitals affiliated with the Universidade de Passo Fundo (UPF) and the Brazilian Health System Sepsis is an important cause of hospitalization and the (SUS).9% and 52. and 65. Exclusion criteria were: the US and found an estimate of 751 thousand cases of ICU stays shorter than 24 hours.000).2%). 2008 . and pregnancy. and found A questionnaire was used to collect data and to keep more than 10 million cases of sepsis and an increase in uniform records for the three ICU. and source of infection were collected. The Brazilian Sepsis Epidemiolo. Overall mortality rates When a variable was absent. it was classified as nor- for sepsis have decreased. Hospital Prontoclínica se grave. and 9 main cause of death in intensive care unit (ICU)1-3. the use of immunosuppressive drugs and mortality rate were also used for the analyses. In to 22 ICU beds. 34% for severe sepsis. naire and definitions of all variables was handed out ported that the prevalence rate of sepsis in ICU ranged to all researchers.6.1%: 6. sepse. in Passo Fundo (population.6%. sepsis. Few studies in. e os germes mais prevalentes foram os bacilos gram-negativos (53. are mal and a value of zero was entered for that variable.6%). METHODS tório (71. of sepsis per year and over 100 thousand deaths in the Patients were included if they were 18 years or older United States4. The general talidade nas UTI de Passo Fundo. still unacceptably high14. but did not go back to a previous stage.3% for septic shock13. 46. the cause of ad- mortality rates of 11%. SIRS. and the tality rates of 16. The incidence of sepsis has The use of antibiotics. Cidade de Passo Fundo (HCPF). and ICU procedures.7% for sepsis. and all patients or their (CDC) estimated an incidence of 450 thousand cases legal guardians signed an informed consent term. SOFA patients with SIRS.6 reviewed data on hospital discharges for study. SOFA scores16 were calculated daily during ICU stay. pitalization according to the Knaus method15. discharge from ICU. hospitals provide care to the population living in the CONCLUSÕES: Sepse é um importante problema de northern area of this state and in the western region of saúde que leva a uma taxa extremamente alta de mor. at 20% to 80%. A manual with de- frequency to 82. Studies tailed information about how to fill out the question- conducted in Europe. more invasive laboratory culture results. predisposing factor for infection.1% to 30%7-11. conducted in five ICU. Abril/Junho. ding to the definitions established by the consensus of te of Rio Grande do Sul. accor- vestigated the epidemiology of sepsis in ICU in the sta. The patients were followed up until from 5. Brazil. Patients increased prevalence of HIV infection. severe sepsis and septic score. 180.6% para sepse grave e city in the State of Rio Grande do Sul. or the 28th day after inclu- gical Study (Bases Study). It was conducted form August 2005 to Fe- de mortalidade foi 31. new admission was classified as a new patient in this Martin et al.9%. APACHE II score. The three are tertiary general hospitals. sepsis. Australia and New Zealand re. 33.8% para choque séptico.

90 and 8. which corres. MICHEL ET AL. and infectious causes.1%) and renal (37.9%) developed infection. the Mann. frequently were cephalosporin (48.3%) and beta-lactamic antibiotics (26.001).4%). in 1.8 for area under the 3 or more organ failures (p < 0. neuro- Whitney test.4% of the patients. sepsis. a cut- fined according to the consensus of the ACCP/SCCM. sepsis. inclusion in the study.7 ± 18.7%. Enterobacter sp and Acinetobacter sp) in 53. where younger than 18 years. 60. for 71. Mean first and last SOFA Statistical Analysis scores of patients that survived was statistically diffe- Data are presented as mean ± SD. and septic shock of SIRS. The authors did not play any role in the decisions made 27.12. se. res. classified according to stages was 6 (2-14). 24 ± 9 (p < 0.1%.5% were men. Abril/Junho. 73%. The antibiotics used most patients consecutively admitted to the ICU were eva. tic shock were 3.7% of all cases tious SIRS. as excellent18-20. under the curve was 0.8 and 0.3% of significance was set at p < 0. ZANON.7 to 0. or data were ventilation in 51%. in 24% of the patients. their data might be entered in more than one stage.8% 13. and mechanical stayed in the ICU for less than 24 hours.734 ± 0. vere sepsis and septic shock were found in 36.0 for Windows (Chicago.5. cultures were tween 0.3%. and gram-positive cocci (Coagulase-ne- for HSVP.8% (Table 2).4%). 2008 .1%. 414 (73. clinical ICU mortality was 31. Mean pinal fluid.6% and 64.6 years. and median ICU stay of patients admitted to the ICU due to neurologic (29. Overall median number of days in missing from their records (Figure 1). 10. During the study. ponds to a prevalence rate of 58%. 971 cases.0%). 34. and 56. agents (36. most frequent symptoms of SIRS were tachycardia Clinical concepts and criteria introduced in the last (82. antianaerobic luated.1%.8% of the cases of infectious SIRS.3%) or surgical (17. in 28.4%.1% of the cases.5 was established as the value to obtain Infection was defined as the presence of pathogenic good sensitivity (67. CAOVILLA. severe sepsis and sep- infection treated with antibiotics or not17. and the most frequent sites of infection statistical analyses.1% of all cases.1%). and fungi. urine (18. cerebros. re. Mean age was Only one antibiotic was used in 26. severe sepsis and septic shock were de. 55. 22. and values between 0. Patients were the ICU was 6 (3-11). and 560 met inclusion criteria. and the Fisher logic (42.8% and 35.7%). for no survivors. The evaluate the or more organs was found for 36. The SPSS the cases. Percentages of total nosa. for no normal variables. Overall piratory (24. was 6. The by the patients’ attending physicians.4 ± 3. for survivors.7%) and were positive in 50.3%) and tachypnea (80%). Failure in 3 Exact test. tients. The level of statistic made for 340 (60. sepsis.6% for patients with ty. Non-infec.8% in patients with used. 130 Revista Brasileira de Terapia Intensiva Vol. and classification of inflammatory events in patients in ICU. 20 Nº 2.6%.2% number of admissions were 50. Mortality for non-infec- tious causes were responsible for 28. were most common in the respiratory (60.8% of the patients were 2. Nosocomial infection was found in 53.001) (Figure 3). System or organ failures to analyze normally distributed variables.02 (Figure 2). nasogastric catheter in did not develop SIRS. area microorganisms in any sterile medium (blood. 36. severe sepsis. affiliated with the Brazilian Health System (SUS) had More than one pathogen was identified in 2.1%) systems.8% of the 87% of all admissions (Table 1).4%). three or more.3%. median (interquartile rent from mean first and last SOFA score of no survi- range) and percentages. According to the SIRS. and ascetic fluid) or the clinical suspicion of SOFA scores for SIRS.6% and 13% of the cases. urinary tract (4%) and surgical wound (3. central venous catheter in 61%.8% and blood (12.1) problems. older than 60 years.6%).65. The Student t test was used vors (p < 0.99. 4. were the lungs (71.9. Overall mean SOFA score was 5. for categorical variables.8%). and on the 28th day after causes were found for 76. discriminatory power of APACHE II scores for mortali. The two teaching hospitals gative Staphylococcus and Staphylococcus aureus). HCPF and HP. off point of 18. mortality rate ranged from 14. The most frequent pathogens were gram-ne- This study was conducted in the general ICU of three gative bacilli (Escherichia coli. be. sepsis.001). it was 15 ± 8.6%) and specificity (67.6%. a receiver operation characteristic curve (ROC) was fewer than 3 organ failures to 59. receiver operating characteristic (ROC) curve. Positive cultures were most frequently RESULTS obtained from sputum (23%). Pseudomonas aerugi- hospitals in Passo Fundo Brazil. US) software was used for of the cases.05 (two-tailed). Four hundred The most important infection risk factors were urethral eleven patients (42%) were excluded because they catheter in 87% of the cases. Overall mean APACHE decade to define SIRS established a more accurate II score was 18 ± 9. 2. Of all study pa- curve were classified as good discrimination and .

Comparison of Mean First and Last SOFA Scores of Figure 2 – APACHE II Score: ROC Curve for ICU Mortality. SEPSIS IN THE INTENSIVE CARE UNIT: ETIOLOGIES. PROGNOSTIC FACTORS AND MORTALITY Figure 1 – Patients Admitted to the Three ICU and Mortality Rates. Figure 3 . Abril/Junho. 20 Nº 2. 2008 . Surviving and Non-Surviving Patients. Revista Brasileira de Terapia Intensiva 131 Vol.

0 (3-5) < 0.20. ZANON.16.8%. Nosocomial infectiona 53.001b our study.10 found mortality rates of 7% and 26.8 mean APACHE II score was 18 ± 9. difference was statistically significant (p < 0. b Median and interquartile range. Table 1 – Demographics and General Data. and a greater score was associated with gre- Table 2 – Data of Patients that Survived and Patients that Died. APACHE II scores were significantly associated with death.0 for septic shock.3 of 34.1% and a rate HCPFa (patients) 36. CAOVILLA.2% Gram negative 53. se reported in a study conducted by Vincent et al.1%.1) quate to obtain good sensitivity (67. sepsis.1 milar to those reported in the literature25.4 14.13. The SOAP study21. HSVPa (patients) 50. it a was 15 ± 8.6 Male sexa 55 patients with sepsis reported general mortality ra- Infectious SIRSa 71.2% Mortality on 28th daya 34. Rangel-Frausto et al. A cut-off point of 18 was Variables Survivals Deaths p found using the ROC curve. a value that was ade- Number of patients (%) 386 (68.5% to 53.6% 1.2 Salvo et al.5 groups of non-infectious SIRS.0 dy (p = 0.3% for septic shock12. Some Last SOFA score 2±2 10 ± 5 < 0.6%). 34.8 ± 16.0 Surgical wound 3. In our study.6%.13.001) b Fisher exact test. This is the first prospective study in our region to 59.0220 (Figure 3).001c last SOFA scores of survivors and no survivors reve- a Student t test. These findings are similar to tho- analyze the occurrence of sepsis in patients ad.4 Brazilian studies reported mortality rates of 11.6 Septic shock mortalitya 64. MICHEL ET AL. Brazilian Non-infectious SIRSa 28. Studies in Europe and the US with Age (mean ± SD) 60.001 a studies reported that it successfully predicted ou- Mean number of organ 1.21.6% SOFA score was associated with overall mortality in ≥3 40. When patients were divided into Severe sepsisa 24. and 46% and 82% Urinary tract 4. and for no survivors.2 for severe sepsis and of 54.0 (2-4) < 0.9) 174 (31.4 sis or septic shock.3 ± 19. Lung 71.6 to 65. 20 Nº 2. Overall Severe sepsis mortalitya 22.26.001c tcome for their patients19. and 52.24 and Community infectiona 46.6% on the 28th day after inclusion in the stu- HPa (patients) 13.6%) and spe- Mean age (years) 59. Gram positive 30.0 (3-11) for non-infectious SIRS.001 a Greatest SOFA score 5±4 12 ± 5 < 0.7 studies found a general ICU mortality rate of 21. (Table 2).7 ± 18. and those with three or more.1%.21-23.0 and 46.27 failures failed to demonstrate the efficacy of APACHE II as Organ failures (%) a predictor of mortality of patients with sepsis. The ≤2 85.8% < 0.5% Infection sitea for non-infectious SIRS. of 16. The use of the APACHE II score First SOFA score 4±2 8±4 < 0. 36% and 16% for sepsis.734 ± APACHE II 15 ± 8 24 ± 9 < 0.0 (4-6) 5. area under the curve was 0. and the Percentage.7 an overall ICU mortality rate of 31.9% for severe sepsis.0 (0-2) 3. results that are similar to those reported in Brazilian and European studies14.8% Sepsisa 32.6 0. The comparison of means. 24 ± 9.3 tes that ranged from 13.4% to 46. found a mortality rate of 32.001 a as a predictor of mortality is controversial. conducted in Pathogensa 198 ICU in Europe.2 59. severe sep- Septic shocka 31.7 20% and 52% for severe sepsis. This study found a high frequency of sepsis. ater likelihood of death.1% for septic shock. for survivors. Abril/Junho. ICU mortality rates were 6. Our overall mortality Non-infectious SIRS mortalitya 6. 22% and 64.001a 0.008a cificity (66.9% for sep- Overall mortality in ICUa 31.3 63.237).1 sis.001). but Lundeberg et al.3% Length of ICU stayb 6.7% to 33.4% 12. DISCUSSION patients with two or fewer organ failures had a mor- tality rate of 14. aled a statistically significant difference (p < 0. 132 Revista Brasileira de Terapia Intensiva Vol. c Mann-Whitney test.8% (p < 0.26.001). mitted to the ICU. Sepsis remains a global medical Variables General challenge and one of the main causes of death in Total number of patients (n) 560 ICU.8 10. 2008 . of the first and Length of ICU stay (days) 6.1 rates and rates according to sepsis stages were si- Sepsis mortalitya 10.

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