In this episode I’ll:
1. Discuss an article about readmission for recurrent sepsis.
2. Answer the drug information question “Does lactated ringers solution have a role in managing the current sodium bicarbonate shortage?”
3. Share a resource for learning about ongoing clinical trials.
Article
Readmissions for Recurrent Sepsis: New or Relapsed Infection?
Lead author: Kimberley Marie DeMerle
Published in Critical Care Medicine July 2017
Background
Patients who are discharged from the hospital after treatment for sepsis are frequently readmitted, often for recurrent sepsis. What is unclear is whether a readmission for sepsis represents a new infection or a recurrence of the original infection. The authors sought to assess the extent to which 90-day readmissions for recurrent sepsis are due to infection of the same site and same pathogen as the initial episode.
Methods
The study was a retrospective cohort of over 450 patients readmitted within 90 days after initial treatment for sepsis.
Results
Of the patients readmitted within 90 days of sepsis, 29% were readmitted with another episode of sepsis. The most common sites of infection were urinary and gastrointestinal. 68% of the readmissions for sepsis were due to the same site as the initial sepsis hospitalization. 19% of readmissions were found to be at the same site and with the same organism. However almost one-third of patients had culture negative sepsis. Due to the uncertainty this creates, over half of the readmissions could have possibly been due to infections with both the same organism and same site.
Conclusion
The authors concluded:
Of the patients readmitted with sepsis within 90 days, two thirds had infection at the same site as their initial admission. Just 19% had infection confirmed to be from the same site and organism as the initial sepsis hospitalization. Half of readmissions were definitively for new infections, whereas an additional 34% were unclear since cultures were negative in one of the hospitalizations.
Discussion
The question of whether to give antibiotic coverage based on culture data from previous hospital stays is one that every clinician has faced. Based on this study, empiric antibiotic coverage should be given against the same organism that caused sepsis in the previous admission. Even if all of the patients with culture negative sepsis are excluded, the 19% of patients with confirmed same-site, same-organism readmission are enough to warrant this practice. However, the previous organism cannot be the sole focus of empiric therapy as many infections were from different organisms or sites.
Drug information question
Q: Does lactated ringers solution have a role in managing the current sodium bicarbonate shortage?
A: Yes!
Lactated ringers contain 28 mEq lactate per liter. According to Dailymed:
Lactate anion [CH3CH(OH)COO−] serves the important purpose of providing “raw material” for subsequent regeneration of bicarbonate (HCO3−) and thus acts as a source (alternate) of bicarbonate when normal production and utilization of lactic acid is not impaired as a result of disordered lactate metabolism.
In the liver, lactate is metabolized to glycogen which is ultimately converted to carbon dioxide and water by oxidative metabolism. The sodium (Na+) ion combines with bicarbonate ion produced from carbon dioxide of the body and thus retains bicarbonate to combat metabolic acidosis (bicarbonate deficiency).
Since metabolic conversion of lactate to bicarbonate is dependent on the integrity of cellular oxidative processes, lactate may be inadequate or ineffective as a source of bicarbonate in patients suffering from acidosis associated with shock or other disorders involving reduced perfusion of body tissues. When oxidative activity is intact, one to two hours time is required for conversion of lactate to bicarbonate.
Resource
The resource for this episode is clinicaltrials.gov. Clinicaltrials.gov is a registry and results database of publicly and privately supported clinical studies of human participants conducted around the world. It is an essential website in my practice. I frequently use it to locate ongoing clinical trials, contact information for site investigators, and trial methodology information.
If you like this post, check out my book – A Pharmacist’s Guide to Inpatient Medical Emergencies: How to respond to code blue, rapid response calls, and other medical emergencies.
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