• 5
    Dec
  • Sepsis in Critically Ill Patients at a Community Acute Care Hospital: RESULTS

Twenty-seven patients received DAA in the study period. With reference to the institution’s criteria for utilization, 26 (96%) of the patients who received DAA were eligible for this type of therapy.

The mean APACHE II score (± standard deviation) was 28 ± 4, and the mean number of dysfunctional organs or systems, according to the criteria in the PROWESS study, was 3 ± 0.9 (Table 1). The lungs (12 patients [44%]) and the abdomen (11 patients [41%]) were the most common sites of infection. There was a greater incidence of gram-positive (12 patients [44%]) than gram-negative (6 patients [22%]) infections, and a significant number of culture results were negative (11 patients [41%]).
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Table 1. Characteristics of Patients Who Received Drotrecogin Alfa (Activated) for Sepsis and Sites and Causes of infection


Characteristic No. (%) of Patients *
(n = 27)


Age (yr), mean ± SD Sex, males


Weight (kg), mean ± SD APACHE II score, mean ± SD


60 ±
20 15 (56) 74 ±16 28
± 4


Dysfunctional organ or system


Mean no. ± SD


3 ±
0.9


Cardiovascular


25 (93)


Respiratory


21 (78)


Renal


13 (48)


Metabolic


11 (41)


Hematologic


4 (15)


Site of infection


Lung


12 (44)


Abdomen


11 (41)


Urinary tract


2 (7)


Central nervous system


1 (4)


Skin and soft tissue


1 (4)


Type of organismt



Gram-positive


12 (44)




Methicillin-sensitive

Staphylococcus aureus


3 (11)




Methicillin-resistant

Staphylococcus aureus


2 (7)



Streptococcus pneumoniae


3 (11)



Other

Streptococcus

species


2 (7)



Enterococcus faecalis


2 (7)



Gram-negative


6 (22)



Klebsiella

spp.


2 (7)



Escherichia coli


1 (4)



Neisseria meningitidis


1 (4)



Morganella morganii


1 (4)



Pseudomonas aeruginosa


1 (4)


Culture-negative


11 (41)


SD =
standard deviation, APACHE
= Acute
Physiology and Chronic Health Evaluation (for which scores of

25 or higher
indicate an increased risk of death). *Unless indicated otherwise.

tFor some patients, more than one organism was cultured.

The planned 96-h infusion of DAA was completed for 16 (59%) of the 27 patients. Among the 11 patients whose entire course of therapy was not completed, the reasons were death (6 patients [55%]), transfer to another institution for dialysis (2 patients [18%]), adverse effect (2 patients [18%]), and contraindication discovered after starting therapy (1 patient [9%]). The mean duration of DAA infusion for all patients was 65 ± 40 h.
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The ICU mortality rate was 44% (12/27). Of these 12 patients, 6 (50%) died within an average of 8 ± 7 h after DAA was started. In this subgroup, the mean APACHE II score was 32 ± 4 and the mean number of dysfunctional organs or systems was 3.5 ± 1.0. For 2 patients (7%), status at 28 days was unknown because they had been transferred to another institution. The 28-day mortality rate of the remaining patients was 60% (15/25).

The rate of serious bleeding during the infusion was 7% (2/27). One of these patients had a significant episode of gastrointestinal bleeding, and the other had serious hemorrhag- ic purpura of the left buttock in conjunction with a platelet count of 23 x 109/L. In both cases, the DAA therapy was stopped because of the adverse event, and the course of therapy was not completed. Both of the patients who experienced serious bleeding died.
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Wastage of DAA occurred with 10 (37%) of the 27 patients. A total of about 145 mg of DAA was wasted at a cost of $9700. Among the patients for whom wastage occurred, the average wastage was 0.9 ± 0.7 bags or 14.5 ± 8.3 mg of drug. Reasons for wastage included patient death, expiry of prepared supply secondary to interruptions in therapy, and discontinuation of therapy because a contraindication was discovered. About half of the wastage (70 mg) occurred because additional supplies of DAA had been prepared before completion of the current bag. The cost associated with this form of wastage was about $4700. Of this wastage, 50 mg (71%) was potentially preventable because the extra bags of DAA had been prepared during regular pharmacy hours. The cost associated with this potentially preventable wastage was $3350.

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