Epidemiology of Hospital-Onset Versus Community-Onset Sepsis in U.S. Hospitals and Association With Mortality: A Retrospective Analysis Using Electronic Clinical Data.

Abstract

OBJECTIVES:

Prior studies have reported that hospital-onset sepsis is associated with higher mortality rates than community-onset sepsis. Most studies, however, have used inconsistent case-finding methods and applied limited risk-adjustment for potential confounders. We used consistent sepsis criteria and detailed electronic clinical data to elucidate the epidemiology and mortality associated with hospital-onset sepsis.

DESIGN:

Retrospective cohort study.

SETTING:

136 U.S. hospitals in the Cerner HealthFacts dataset.

PATIENTS:

Adults hospitalized in 2009-2015.

INTERVENTIONS:

None.

MEASUREMENTS AND MAIN RESULTS:

We identified sepsis using Centers for Disease Control and Prevention Adult Sepsis Event criteria and estimated the risk of in-hospital death for hospital-onset sepsis versus community-onset sepsis using logistic regression models. In patients admitted without community-onset sepsis, we estimated risk of death associated with hospital-onset sepsis using Cox regression models with sepsis as a time-varying covariate. Models were adjusted for baseline characteristics and severity of illness. Among 2.2 million hospitalizations, there were 95,154 sepsis cases: 83,620 (87.9%) community-onset sepsis and 11,534 (12.1%) hospital-onset sepsis (0.5% of hospitalized cohort). Compared to community-onset sepsis, hospital-onset sepsis patients were younger (median 66 vs 68 yr) but had more comorbidities (median Elixhauser score 14 vs 11), higher Sequential Organ Failure Assessment scores (median 4 vs 3), higher ICU admission rates (61% vs 44%), longer hospital length of stay (median 19 vs 8 d), and higher in-hospital mortality (33% vs 17%) (p < 0.001 for all comparisons). On multivariate analysis, hospital-onset sepsis was associated with higher mortality versus community-onset sepsis (odds ratio, 2.1; 95% CI, 2.0-2.2) and patients admitted without sepsis (hazard ratio, 3.0; 95% CI, 2.9-3.2).

CONCLUSIONS:

Hospital-onset sepsis complicated one in 200 hospitalizations and accounted for one in eight sepsis cases, with one in three patients dying in-hospital. Hospital-onset sepsis preferentially afflicted ill patients but even after risk-adjustment, they were twice as likely to die as community-onset sepsis patients; in patients admitted without sepsis, hospital-onset sepsis tripled the risk of death. Hospital-onset sepsis is an important target for surveillance, prevention, and quality improvement initiatives.

• Authors: Chanu Rhee, Rui Wang, Zilu Zhang, David Fram, Sameer S Kadri, Michael Klompas, CDC Prevention Epicenters Program
• Journal: Critical care medicine (Crit Care Med) Vol. 47 Issue 9 Pg. 1169-1176 (09 2019) ISSN: 1530-0293 [Electronic] United States
• PMID: 31135503 (Publication Type: Journal Article, Research Support, N.I.H., Intramural, Research Support, U.S. Gov't, P.H.S.)

Topics

• Adult
• Age Distribution
• Aged
• Aged, 80 and over
• Community-Acquired Infections
• Comorbidity
• Cross Infection (epidemiology)
• Female
• Hospital Mortality
• Humans
• Intensive Care Units (statistics & numerical data)
• Length of Stay (statistics & numerical data)
• Logistic Models
• Male
• Middle Aged
• Organ Dysfunction Scores
• Proportional Hazards Models
• Retrospective Studies
• Sepsis (epidemiology, mortality)
• Severity of Illness Index
• United States