Daily Sepsis Research Analysis
Three studies advance sepsis prevention and early management across systems-level and bedside domains: (1) a decision-analytic model shows targeted chlorhexidine bathing and nasal decolonization is broadly cost-effective for reducing hospital-onset bacteremia/fungemia, (2) a multicountry interrupted time series demonstrates a digital Smart Triage platform shortened time to IV antibiotics and reduced antimicrobial use and admissions, and (3) dual national cohorts reveal that secondary SBP prophyl
Summary
Three studies advance sepsis prevention and early management across systems-level and bedside domains: (1) a decision-analytic model shows targeted chlorhexidine bathing and nasal decolonization is broadly cost-effective for reducing hospital-onset bacteremia/fungemia, (2) a multicountry interrupted time series demonstrates a digital Smart Triage platform shortened time to IV antibiotics and reduced antimicrobial use and admissions, and (3) dual national cohorts reveal that secondary SBP prophylaxis in cirrhosis is associated with increased non-SBP infections, underscoring stewardship risks.
Research Themes
- Infection prevention and decolonization strategies to reduce hospital-onset bacteremia/fungemia
- Digital triage and quality improvement to accelerate sepsis recognition and treatment
- Antimicrobial stewardship trade-offs in secondary prophylaxis for cirrhosis
Selected Articles
1. Universal vs Targeted Chlorhexidine Bathing and Nasal Decolonization in Hospitalized Patients.
Using a decision-analytic model informed by the cluster-randomized ABATE trial, targeted chlorhexidine bathing and nasal decolonization for patients with medical devices was cost-effective from both payer and hospital perspectives across broad scenarios. Universal decolonization minimized HOB events but required higher incremental costs per event averted and may be preferable only in high-device or low-adherence settings.
Impact: This analysis directly informs hospital policy by quantifying cost-effectiveness trade-offs for decolonization strategies aimed at reducing hospital-onset bloodstream and fungal infections, a key sepsis prevention lever.
Clinical Implications: Adopt targeted decolonization for general medical/surgical units as the default, reserving universal decolonization for high-device units or when targeted adherence is poor; align infection prevention with payer and hospital willingness-to-pay thresholds.
Key Findings
- In the base case, standard of care was least effective and most costly; targeted decolonization was least costly.
- Universal decolonization achieved the fewest HOB events but had ICERs of $119,700 (payer) and $126,600 (hospital) per HOB averted versus targeted.
- Targeted decolonization was cost-effective across broad scenarios; universal may be preferred in high device-prevalence units or with low targeted adherence.
Methodological Strengths
- Decision-analytic model calibrated to a large cluster-randomized trial (>500,000 admissions)
- Comprehensive sensitivity analyses under payer and hospital perspectives
Limitations
- Model outcomes depend on assumptions (adherence, costs, effect sizes) and willingness-to-pay thresholds
- Generalizability may vary by unit case mix and implementation fidelity
Future Directions: Prospective implementation studies comparing targeted vs universal strategies by unit type, with real-world adherence, resistance ecology, and equity outcomes.
2. Implementation of Smart Triage combined with a quality improvement program for children presenting to facilities in Kenya and Uganda: An interrupted time series analysis.
In Kenya, Smart Triage reduced time to IV antibiotics by 98 minutes (57%) compared to baseline and opposite trends at control sites, while Uganda saw non-sustained effects. Both settings showed substantial reductions in antimicrobial utilization and admissions; mortality decreases were observed but were secondary outcomes and warrant cautious interpretation.
Impact: Demonstrates real-world, multi-site implementation of a digital triage platform that improved timeliness of antibiotic delivery and reduced antimicrobial use/admissions in LMIC pediatric settings.
Clinical Implications: Adopting digital triage with integrated QI can shorten delays to IV antibiotics and reduce unnecessary antimicrobial exposure; context-specific barriers (e.g., staffing, COVID-19 disruptions) must be addressed to sustain gains.
Key Findings
- Kenya intervention sites achieved a 98-minute (57%, 95% CI 81–114) reduction in time to IV antibiotics during implementation, while control sites increased by 49 minutes.
- Antimicrobial utilization decreased by 47% (Kenya) and 33% (Uganda) at intervention sites versus baseline.
- Admission rates decreased by 47% (Kenya) and 33% (Uganda), with mortality reductions of 25% and 75% respectively (secondary outcomes).
Methodological Strengths
- Controlled interrupted time series across multiple sites with pre-specified registration (NCT04304235)
- Objective operational metrics (time to antibiotics, antimicrobial use) and concurrent controls
Limitations
- Heterogeneous effects and non-sustained improvements in Uganda; potential confounding from COVID-19 and resource constraints
- Mortality and admission outcomes were secondary and not powered as primary endpoints
Future Directions: Hybrid effectiveness-implementation trials to optimize fidelity, sustainability, and equity; integration with antimicrobial stewardship and diagnostics to refine triage thresholds.
3. Secondary Spontaneous Bacterial Peritonitis Prophylaxis Is Associated With a Higher Rate of Infections other than Spontaneous Bacterial Peritonitis in 2 US-Based National Cirrhosis Cohorts.
Across VA and non-VA national cohorts of cirrhosis with SBP, secondary SBP prophylaxis was consistently associated with increased non-SBP infections (UTI, pneumonia, bacteremia, C. difficile). Findings emphasize potential unintended harms and the need to refine prophylaxis strategies.
Impact: Large, complementary real-world cohorts reveal a reproducible association between secondary prophylaxis and broader infection risk, informing stewardship and guideline reassessment.
Clinical Implications: Reassess routine secondary SBP prophylaxis; prioritize risk stratification, narrow durations, and active surveillance for non-SBP infections; integrate with transplant evaluation and ascites management.
Key Findings
- VA-CDW cohort (n=4,673): SecSBPPr associated with any non-SBP infection (OR 1.26) and UTI (OR 1.21).
- TriNetX cohort (n=6,708): SecSBPPr associated with any non-SBP infection (OR 1.33), UTI (OR 1.35), pneumonia (OR 1.35), and bacteremia (OR 1.47).
- Consistency across two national datasets strengthens the association between prophylaxis and increased non-SBP infections.
Methodological Strengths
- Two large, complementary national cohorts with multivariable regression
- Consistent findings across VA and non-VA systems enhance external validity
Limitations
- Observational design with potential confounding by indication and misclassification from coding
- Antibiotic agents, dosing, and resistance patterns not granularly characterized
Future Directions: Prospective trials or quasi-experimental designs to test risk-adapted, time-limited prophylaxis and evaluate impacts on microbiome, resistance, and sepsis-related outcomes.