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ARTICLE | July 26, 1995

Long-term Survival and Function After Suspected Gram-negative Sepsis FREE

Trish M. Perl, MD, MSc; LuAnn Dvorak, LPN; Taekyu Hwang, MS; Richard P. Wenzel, MD, MSc

[+] Author Affiliations

Presented in part at the 1993 Interscience Conference on Antimicrobial Agents and Chemotherapy, New Orleans, La, October 19, 1993.

Reprint requests to the Department of Internal Medicine, C41 GH, University of Iowa College of Medicine, Iowa City, IA 52242 (Dr Perl).

Concepts in Emergency and Critical Care section editor: Roger C. Bone, MD, Consulting Editor, JAMA.

Advisory Panel: Bart Chernow, MD, Baltimore, Md; David Dantzker, MD, New Hyde Park, NY; Jerrold Leiken, MD, Chicago, Ill; Joseph E. Parrillo, MD, Chicago, Ill; William J. Sibbald, MD, London, Ontario; and Jean-Louis Vincent, MD, PhD, Brussels, Belgium.

JAMA. 1995;274(4):338-345. doi:10.1001/jama.1995.03530040066043

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ABSTRACT

ABSTRACT | REFERENCES

Objective. —To determine the long-term (>3 months) survival of septic patients, to develop mathematical models that predict patients likely to survive long-term, and to measure the health and functional status of surviving patients.

Setting. —A large tertiary care university hospital and an associated Veterans Affairs Medical Center.

Design. —From December 1986 to December 1990, a total of 103 patients with suspected gram-negative sepsis entered a double-blind, placebo-controlled efficacy trial of monoclonal antiendotoxin antibody. Of these, we followed up 100 patients for 7667 patient-months. Beginning in May 1992, we reviewed hospital records and contacted all known survivors. We measured the health status of all surviving patients.

Main Outcome Measures. —The determinants of long-term survival (up to 6 years) were identified through two Cox proportional hazard regression models: one that included patient characteristics identified at the time of sepsis (bedside model) and another that included bedside, infection-related, and treatment characteristics (overall model).

Results. —Of the 60 patients in the cohort who died at a median interval of 30.5 days after sepsis, 32 died within the first month of the septic episode, seven died within 3 months, and four more died within 6 months. In the bedside multivariate model constructed to predict long-term survival, large hazard ratios (HRs) were associated with severity of underlying illness as classified by McCabe and Jackson criteria (for rapidly fatal disease, HR=30.4, P<.001; for ultimately fatal disease, HR=7.6, P<.001) and the use of vasopressors (HR=2.5; P=.001). In the overall model for long-term survival, severity of underlying illness (rapidly fatal disease, HR=23.7, P<.001; ultimately fatal disease, HR=6.5, P<.001), number of active co-morbid illnesses (HR=1.3; P=.04), use of vasopressors at the time of sepsis (HR=2.0; P=.02), and development of adult respiratory distress syndrome (HR=2.3; P=.02) predicted patients most likely to die. The Acute Physiology and Chronic Health Evaluation II score was not a significant predictor of outcome when either model included the simpler McCabe and Jackson classification of underlying disease severity. We compared the health status scores with norms for the general population and found that patients with resolved sepsis reported more physical dysfunction (P<.001), including problems with work and activities of daily living (P=.02), and more poorly perceived general health (P<.01). In contrast, patients' scores for perceived emotional health were higher than those in the general population (P=.004). The mean Barthel score of our patients was 85 (100=total independence) and the mean Eastern Cooperative Oncology Group score was 0.7 (0=normal, 4=100% bedridden), suggesting that the patient's physical function was not normal.

Conclusions. —At the onset of suspected gram-negative sepsis, severity of underlying illness and in-hospital use of vasopressors are strong and consistent predictors of short- and long-term survival. Our data validate the McCabe and Jackson severity of illness scoring system for predicting long-term survival after sepsis. Physical dysfunction and more poorly perceived general health occur commonly after sepsis.(JAMA. 1995;274:338-345)

REFERENCES

ABSTRACT | REFERENCES

Office of Planning and Extramural Programs and Hospital Care Statistics, Division of Health Care Statistics, National Center for Health Statistics. Increase in national hospital discharge survey rates for septicemia—United States, 1979-1987. MMWR Morb Mortal Wkly Rep . 1990;;39:31-34.

Martin MA. Epidemiology and clinical impact of gram-negative sepsis. Infect Dis Clin North Am . 1991;;5:739-752.

Bone RC. Gram-negative sepsis: background, clinical features, and intervention. Chest . 1991;;100: 802-808.

Ziegler EJ, Fisher CJ Jr, Sprung CL, et al, for the HA-1A Sepsis Study Group. Treatment of gram-negative bacteremia and septic shock with HA-1A human monoclonal antibody against endotoxin: a randomized, double blind, placebo-controlled trial. N Engl J Med . 1991;;324:429-436.

Greenman RL, Schein RMH, Martin MA, et al, for the XOMA Sepsis Study Group. A controlled clinical trial of E5 murine monoclonal IgM antibody to endotoxin in the treatment of gram-negative sepsis. JAMA . 1991;;266:1097-1102.

Bone RC, Balk RA, Fein AM, et al. A second large controlled clinical study of E5, a monoclonal antibody to endotoxin: results of a prospective multicenter, randomized, controlled trial. Crit Care Med . 1995;;23:994-1005.

Warren HS, Danner RL, Munford RS. Anti-endotoxin monoclonal antibodies. N Engl J Med . 1992;; 326:1153-1157.

Massanari RM, Arking L. Long-term outcome in patients with gram-negative septicemia. Infect Control Hosp Epidemiol . 1993;;14:430. Abstract M8.

Bates DW, Pruess KE, Lee TH. How bad are bacteremia and sepsis: outcomes in a cohort with suspected bacteremia. Arch Intern Med . 1995;;155: 593-598.

Perl TM, Lockwood WW, Martin M, Costigan MD, Haynes BS, Wenzel RP. Influence of anti-endotoxin antibody (E5) on long-term post-hospital survival after sepsis. Clin Res . 1992;;40:286A.

Elliot CG, Morris AH, Cengiz M. Pulmonary function and exercise gas exchange in survivors of adult respiratory distress syndrome. Am Rev Respir Dis . 1981;;123:492-495.

Alberts WM, Priest GR, Moser KM. The outlook for survivors of ARDS. Chest . 1983;;84:272-274.

Lakshminarayan S, Hudson LD. Pulmonary function following adult respiratory distress syndrome. Sem Resp Med . 1981;;11:160-164.

Bone RC, Fisher CJ, Clemmer TP, et al. Sepsis syndrome: a valid clinical entity. Crit Care Med . 1989;;17:389-393.

Bone RC. Gram-negative sepsis: a dilemma of modern medicine. Clin Microbiol Rev . 1993;;6:57-68.

The ACCP/SCCM Consensus Conference Committee. Definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis. Chest . 1992;;101:1644-1655.

Bone RC. Toward an epidemiology and natural history of SIRS (systemic inflammatory response syndrome). JAMA . 1992;;268:3452-3455.

McCabe WR, Jackson GG. Gram-negative bacteremia, I: etiology and ecology. Arch Intern Med . 1962;;110:847-853.

Gross PA, DeMauro PJ, Van Antwerpen C, Wallenstein S, Chiang S. Number of comorbidities as a predictor of nosocomial infection acquisition. Infect Control Hosp Epidemiol . 1988;;9:497-500.

Pittet D, Thiévent B, Wenzel RP, Li N, Gurman G, Suter PM. Importance of pre-existing co-morbidities for prognosis of septicemia in critically ill patients. Intensive Care Med . 1993;;19:265-272.

Knaus WA, Draper EA, Wagner DP, Zimmerman JE. APACHE II: a severity of disease classification system. Crit Care Med . 1985;;13:818-829.

Mahoney FI, Barthel DW. Functional evaluation: the Barthel index. Md Med J . 1965;;14:61-65.

Minna JD, Pass H, Glatstein E, Ihde D. Cancer of the lung. In: DeVita VT, Helman S, Rosenberg SA, eds. Cancer: Principles and Practice . 3rd ed. Philadelphia, Pa: JB Lippincott Co; 1989;.

Jette AM, Cleary PD. Functional disability assessment. Phys Ther . 1987;;67:1854-1859.

Somervell PD, Kaplan BH, Heiss G, Tyroler HA, Kleinbaum DG, Obrist PA. Psychologic distress as a predictor of mortality. Am J Epidemiol . 1989;;130:1013-1017.

Ware JE, Sherbourne CD. The MOS 36-item short form health survey (SF-36), 1: conceptual framework and item selection. Med Care . 1992;;30: 473-483.

Ware JE, Snow KS, Kosinski MA, Gandek B. SF-36 Health Survey: Manual and Interpretation Guide . Boston, Mass: The Health Institute, New England Medical Center; 1993;.

Cox DR, Oakes D. Analysis of Survival Data . London, England: Chapman & Hall; 1984;.

Rangel-Frausto MS, Pittet D, Costigan M, Hwang T, Davis CS, Wenzel RP. The natural history of the systemic inflammatory response syndrome (SIRS): a prospective study. JAMA . 1995;; 273:117-123.

Roberts FJ, Geere IW, Coldamn A. A three-year study of positive blood cultures, with emphasis on prognosis. Rev Infect Dis . 1991;;13:34-46.

Chelluri L, Pinsky MR, Donahoe MP, Grenvik A. Long-term outcome of critically ill elderly patients requiring intensive care. JAMA . 1993;;269: 3119-3123.

Wu AW, Damiano AM, Lynn J, et al. Predicting future functional status for seriously ill hospitalized adults: the SUPPORT prognostic model. Ann Intern Med . 1995;;122:342-350.

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Country-Specific Mortality and Growth Failure in Infancy and Yound Children and Association With Material Stature

Use interactive graphics and maps to view and sort country-specific infant and early dhildhood mortality and growth failure data and their association with maternal