could lead to overprescribing of antibiotics. As opposed to other CMS core measure guidelines, sepsis lacks an objective test or event to define the syndrome. Even sepsis experts often disagree about whether patients have sepsis, and more than 40 percent of patients with a working diagnosis of sepsis do not ultimately have the condition.3, 12 Anyone who abstracts charts for sepsis quality review purposes can attest that, even with all the data available, it can be quite difficult to separate cases of sepsis from noninfectious conditions. Inappropriate administration of antibiotics in patients who are not infected, or would not benefit from antibiotics (such as those with viral infections), has negative consequences for the individual patient and hospital populations in general. This riskbenefit ratio becomes all the more skewed as we include patients in the sepsis-screening algorithms who have sepsis but do not have shock or organ dysfunction. In the rush to meet the rigid time frames, broad-spectrum antibiotics will be given more frequently to uninfected patients with syndromes that mirror sepsis. MOVING FORWARD WITH SEPSIS BUNDLES While the increased rates of antibiotic use and HCFO CDI rates during our STOPSepsis implementation were worrisome, we were encouraged to see that these trends seemed to reverse as the program became more widely adopted. The longer-term effects (over several years) are still unknown. Optimistically, it is possible that providers have become more familiar at distinguishing sepsis and are therefore using antibiotics for a more appropriate patient population, as opposed to reflexively prescribing antibiotics to any patient who screened into the STOP-Sepsis program. Alternatively, increased adherence to another recommendation of the SSC guidelines—daily antibiotic reassessment and de-escalation when appropriate—may have become more widespread. Of course, it is also possible that the changes were due to factors unrelated to the sepsis initiative. Integrated sepsis care bundles streamline evaluation and treatment, yet our research is a reminder that providers must face the difficult task of delivering timely sepsis care
while also mitigating unintended consequences. We do not by any means discourage early broad-spectrum antibiotic administration in the septic patient, but further research is required to explore what other effects may come from the implementation of the CMS guidelines. Areas for investigation include the effects on HCFO CDI rates that we have attempted to highlight, as well as potential associations with antimicrobial resistance, laboratory overtesting, and excessive volume administration. We hope that identifying any adverse outcomes will allow the sepsis community to identify changes to further improve a program that has been demonstrated to save lives. Robert Hiensch, MD, is an assistant professor in Medicine, Pulmonary, Critical Care and Sleep Medicine Departments at the Icahn School of Medicine at Mount Sinai. He served as chief fellow during his final year of pulmonary and critical care training, and was awarded the Alvin S. Teirstein, MD, Fellow Award for excellence in clinical practice, teaching, and research. References 1. Gaieski DF, Edwards JM, Kallan MJ, et al. Benchmarking the incidence and mortality of severe sepsis in the United States. Crit Care Med 2013;41:1167-1174. 2. Dellinger RP, Levy MM, Rhodes A, et al. Surviving Sepsis Campaign: International guidelines for management of severe sepsis and septic shock: 2012. Crit Care Med 2013;41:580-637. 3. Mukherjee V, Evans L. Implementation of the Surviving Sepsis Campaign guidelines. Curr Opin Crit Care 2017;23(5):412-416. 4. Rhee C, Kadri SS, Danner RL, et al. Diagnosing sepsis is subjective and highly variable: A survey of intensivists using case vignettes. Crit Care 2016;20:89. 5. Levy MM, Dellinger RP, Townsend SR, et al. The Surviving Sepsis Campaign: Results of an international guideline-based performance improvement program targeting severe sepsis. Intensive Care Med 2010;36(2):222-231. 6. Levy MM, Rhodes A, Phillips GS, et al. Surviving Sepsis Campaign: Association between performance metrics and outcomes in a 7.5-year study. Crit Care Med 2015;43:3-12. 7. Kumar A, Roberts D, Wood KE, et al. Duration of hypotension before initiation of effective antimicrobial therapy is the critical determinant of survival in human septic shock. Crit Care Med 2006;34:1589-1596. 8. Klompas, M, Rhee C. The CMS Sepsis Mandate: Right disease, wrong measure. Ann Intern Med 2016;165(7):517-518. 9. Vogel, L. EMR alert cuts sepsis deaths. CMAJ 2014;186(2):E80. 10. Magill SS, Edwards JR, Bamberg W, et al. Multistate pointprevalence survey of healthcare-associated infections. N Engl J Med 2014;370:1198-1208.
READ MORE ABOUT SEPSIS IN THE AMERICAN JOURNAL OF INFECTION CONTROL Epidemiology of bloodstream infections caused by methicillin-resistant Staphylococcus aureus at a tertiary care hospital in New York. Yasmin M, El Hage H, Obeid R, et al., American Journal of Infection Control, Volume 44 Issue 1, 41–46. Impact of an electronic sepsis initiative on antibiotic use and healthcare facility–onset Clostridium difficile infection rates. Hiensch R, Poeran J, Saunders-Hao P, et al., American Journal of Infection Control, Volume 45, Issue 10, 1091–1100. Mortality in intensive care: The impact of bacteremia and the utility of systemic inflammatory response syndrome. Brooks D, Smith A, Young D, et al., American Journal of Infection Control, Volume 44, Issue 11, 1291–1295.
READ MORE ABOUT CLOSTRIDIUM DIFFICILE IN THE AMERICAN JOURNAL OF INFECTION CONTROL Hospital Clostridium difficile infection (CDI) incidence as a risk factor for hospital-associated CDI. Miller AC, Polgreen LA, Cavanaugh JE, et al., American Journal of Infection Control, Volume 44, Issue 7, 825–829. Impact of an electronic sepsis initiative on antibiotic use and health care facility–onset Clostridium difficile infection rates. Hiensch R, Poeran J, Saunders-Hao P, et al., American Journal of Infection Control, Volume 45, Issue 10, 1091–1100. Prevalence of Clostridium difficile infection in acute care hospitals, long-term care facilities, and outpatient clinics: Is Clostridium difficile infection underdiagnosed in long-term care facility patients? Krishna A, Pervaiz A, Lephart P, et al., American Journal of Infection Control, Volume 45, Issue 10, 1157–1159.
11. Gilbert D, Kalil A, Klompas M, et al. Infectious Diseases Society of America (IDSA) position statement: Why IDSA did not endorse the Surviving Sepsis Campaign guidelines. Clin Infect Dis 2017. doi: 10.1093/cid/cix997. 12. Klouwenberg PM, Cremer OL, van Vught LA, et al. Likelihood of infection in patients with presumed sepsis at the time of intensive care unit admission: A cohort study. Crit Care 2015;19:319.
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