Effect of a multifaceted educational intervention for anti-infectious measures on sepsis mortality: a cluster randomized trial

被引：144

作者：

Bloos, Frank ^{[1
,2
]}

Rueddel, Hendrik ^{[1
,2
]}

Thomas-Rueddel, Daniel ^{[1
,2
]}

Schwarzkopf, Daniel ^{[1
]}

Pausch, Christine ^{[3
]}

Harbarth, Stephan ^{[4
]}

Schreiber, Torsten ^{[5
]}

Guerndling, Matthias ^{[6
]}

Marshall, John ^{[7
,8
]}

Simon, Philipp ^{[9
]}

Levy, Mitchell M. ^{[10
]}

Weiss, Manfred ^{[11
]}

Weyland, Andreas ^{[12
]}

Gerlach, Herwig ^{[13
]}

Schuerholz, Tobias ^{[14
,15
]}

Engel, Christoph ^{[3
]}

Matthaeus-Kraemer, Claudia ^{[1
]}

Scheer, Christian ^{[6
]}

Bach, Friedhelm ^{[16
]}

Riessen, Reimer ^{[17
]}

Poidinger, Bernhard ^{[1
]}

Dey, Karin ^{[18
]}

Weiler, Norbert ^{[19
]}

Meier-Hellmann, Andreas ^{[20
]}

Haeberle, Helene H. ^{[21
]}

Woebker, Gabriele ^{[22
]}

Kaisers, Udo X. ^{[9
,23
]}

Reinhart, Konrad ^{[1
,2
]}

机构：

[1] Jena Univ Hosp, CSCC, Jena, Germany

[2] Jena Univ Hosp, Dept Anesthesiol & Intens Care Med, Jena, Germany

[3] Univ Leipzig, Inst Med Informat Stat & Epidemiol, Leipzig, Germany

[4] Hop Univ Geneve, Serv Prevent & Controle Infect, Geneva, Switzerland

[5] Zent Klin Bad Berka GmbH, Dept Anaesthesia & Intens Care Med, Bad Berka, Germany

[6] Univ Hosp Greifswald, Dept Anesthesiol & Intens Care Med, Greifswald, Germany

[7] Univ Toronto, St Michaels Hosp, Dept Surg, Toronto, ON, Canada

[8] Univ Toronto, St Michaels Hosp, Li Ka Shing Knowledge Inst, Toronto, ON, Canada

[9] Univ Hosp Leipzig, Dept Anesthesiol & Intens Care Med, Leipzig, Germany

[10] Brown Univ, Warren Alpert Med Sch, Div Pulm & Crit Care Med, Providence, RI 02912 USA

[11] Univ Hosp Ulm, Dept Anesthesiol, Ulm, Germany

[12] Univ Hosp Oldenburg, Dept Anesthesiol & Intens Care Med, Oldenburg, Germany

[13] Vivantes Hosp Neukolln, Dept Anesthesiol Surg Intens Care Med & Pain Ther, Berlin, Germany

[14] Univ Hosp RWTH Aachen, Dept Intens Care Med, Aachen, Germany

[15] Univ Hosp Rostock, Dept Anesthesiol & Intens Care Med, Rostock, Germany

[16] Bethel Hosp Bielefeld, Dept Anesthesiol Intens Care Transfus & Emergency, Bielefeld, Germany

[17] Univ Hosp Tubingen, Dept Internal Med, Tubingen, Germany

[18] Hosp Bundeswehr Berlin, Dept Anesthesiol & Intens Care Med, Berlin, Germany

[19] Univ Med Ctr Kiel, Dept Anesthesiol & Intens Care Med, Kiel, Germany

[20] Helios Hosp Erfurt, Dept Anesthesiol Intens Care Med & Pain Therapy, Erfurt, Germany

[21] Univ Hosp Tubingen, Dept Anesthesiol & Intens Care Med, Tubingen, Germany

[22] Helios Hosp Wuppertal, Dept Intens Care Med, Wuppertal, Germany

[23] Univ Hosp Ulm, Ulm, Germany

来源：

INTENSIVE CARE MEDICINE | 2017年 / 43卷 / 11期

关键词：

Critical illness; Septic shock/drug therapy; Antimicrobial agents; Quality improvement; INTENSIVE-CARE UNITS; RAPID RESPONSE TEAM; QUALITY-OF-CARE; SEPTIC SHOCK; ANTIMICROBIAL THERAPY; CRITICAL DETERMINANT; IMPROVEMENT; SURVIVAL; IMPLEMENTATION; MULTICENTER;

D O I：

10.1007/s00134-017-4782-4

中图分类号：

R4 [临床医学];

学科分类号：

100218 [急诊医学];

摘要：

Purpose: Guidelines recommend administering antibiotics within 1 h of sepsis recognition but this recommendation remains untested by randomized trials. This trial was set up to investigate whether survival is improved by reducing the time before initiation of antimicrobial therapy by means of a multifaceted intervention in compliance with guideline recommendations. Methods: The MEDUSA study, a prospective multicenter cluster-randomized trial, was conducted from July 2011 to July 2013 in 40 German hospitals. Hospitals were randomly allocated to receive conventional continuous medical education (CME) measures (control group) or multifaceted interventions including local quality improvement teams, educational outreach, audit, feedback, and reminders. We included 4183 patients with severe sepsis or septic shock in an intention-to-treat analysis comparing the multifaceted intervention (n = 2596) with conventional CME (n = 1587). The primary outcome was 28-day mortality. Results: The 28-day mortality was 35.1% (883 of 2596 patients) in the intervention group and 26.7% (403 of 1587 patients; p = 0.01) in the control group. The intervention was not a risk factor for mortality, since this difference was present from the beginning of the study and remained unaffected by the intervention. Median time to antimicrobial therapy was 1.5 h (interquartile range 0.1-4.9 h) in the intervention group and 2.0 h (0.4-5.9 h; p = 0.41) in the control group. The risk of death increased by 2% per hour delay of antimicrobial therapy and 1% per hour delay of source control, independent of group assignment. Conclusions: Delay in antimicrobial therapy and source control was associated with increased mortality but the multifaceted approach was unable to change time to antimicrobial therapy in this setting and did not affect survival.

引用

页码：1602 / 1612

页数：11

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