Effect of a multifaceted educational intervention for anti-infectious measures on sepsis mortality: a cluster randomized trial
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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.
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.
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.
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.
KeywordsCritical illness Septic shock/drug therapy Antimicrobial agents Quality improvement
MEDUSA contributing sites and site investigators, alphabetical by site
University Hospital RWTH Aachen, Department of Intensive Care Medicine: Gernot Marx, Achim Schindler, Tobias Schürholz; Ilm-Kreis-Kliniken Arnstadt, Department of Anesthesiology and Intensive Care Medicine: Heike Schlegel-Höfner, Gunther Lehmann, Annett Sander, Steffen Friese, Christian Scholz; Helios Hospital Aue, Department of Anesthesiology and Intensive Care Medicine: Pia Fischer; Zentralklinik Bad Berka GmbH, Department of Anaesthesia and Intensive Care Medicine: Christina Fuchs, Lutz Becher, Norbert Salewsky, Torsten Schreiber; Charité Berlin, Department of Anesthesiology and Operative Intensive Care Medicine: Anton Goldmann, Didier Keh, Katrin Schmid; Hufeland-Klinikum Bad Langensalza, Department of Anesthesiology and Intensive Care Medicine: Winfried Menning, Renate Steuckart; Bundeswehrkrankenhaus Berlin, Department of Anesthesiology and Intensive Care Medicine: Robert Barz, Karin Dey, Meike Fahrenholz, Martin Müller; Vivantes Klinikum Neukölln-Berlin, Department of Anesthesiology, Surgical Intensive Care Medicine, and Pain Therapy: Herwig Gerlach, Susanne Toussaint; Helios Hospital Berlin-Buch, Department of Intensive Care Medicine: Jörg Brederlau; Ev. Hospital Bielefeld, Department of Anesthesiology, Emergency and Intensive Care Medicine, and Pain Therapy: Friedhelm Bach, Dirk Buschmann, Ingo Gummelt, J. Hoeschen, Marion Klaproth, Ina Vedder; HELIOS-Hospital St. Josefs-Hospital Bochum-Linden, Department of Anesthesiology: Ulrike Bachmann-Holdau; St. Georg Hospital Eisenach, Department of Anesthesiology and Intensive Care Medicine: Jürgen Eiche, Rolf Hauschild; Hospital Rudolf Elle, Eisenberg, Department of Anesthesiology and Intensive Care Medicine: Martina Lange, Davia Herrmann-Karbaum; Helios-Hospital Emil-von Behring, Department of Interdisciplinary Intensive Care and Emergency Medicine: Annette Lubasch, Marcus Rücker; Helios-Hospital Erfurt, Department of Anesthesiology and Intensive Care Medicine: Christian Icke, Alexander Lucht, Andreas Meier-Hellmann, Jan Wagner; Catholic Hospital St. Johann Nepomuk Erfurt, Department of Anesthesiology and Intensive Care Medicine: Olaf Arnold, Steffen Kästner, Tobias Clausen; Hospital Friedberg, Department of Internal Medicine: Michael Sternkopf, Robert Voswinckel; SRH Waldklinikum Gera, Department of Anesthesiology and Intensive Care Medicine: T. Benndorf, Christel Eiserloh, Gerhard Kuhnle, Mathias Koch; University Hospital Greifswald, Department of Anesthesiology and Intensive Care Medicine: Manuela Gerber, Matthias Gründling, Liane Guderian, Sven-Olaf Kuhn, Christian Scheer; Hospital Ilmenau; Department of Anesthesiology and Intensive Care Medicine: Gerd Scheiber; Jena University Hospital, Center for Sepsis Control & Care/Department of Anesthesiology and Intensive Care Medicine: Frank Bloos, Susann Christink, Martina Kortegast, Claudia Matthäus-Krämer, Marcel Mücke, Bernhard Poidinger, Hendrik-Rüddel, Ulrike Redlich, Daniel Schwarzkopf, Daniel Thomas-Rüddel, Christel Volkmer; University Hospital Kiel, Department of Anesthesiology and Intensive Care Medicine: Stefanie D’Aria, Thees Lemke, Birgit Michaelsen, Dirk Schädler, Nina Schulz-Ruhtenberg, Norbert Weiler; Hospital Landshut-Achdorf, Department of Anesthesiology and Surgical Intensive Care Medicine: Martin Anetseder, Zoran Textor; University Hospital Leipzig, Department of Anesthesiology and Intensive Care Medicine: Udo Kaisers, Philipp Simon; Hospital Meiningen, Department of Intensive Care and Emergency Medicine: Georg Braun, Nicole Jensen, Werner Gegenfurtner, Alexander Meinhardt, Robert Schmitt, Andrea Teichert; Saale-Unstrut-Hospital Naumburg, Department of Anesthesiology and Intensive Care Medicine: Klaus-Dieter Becker; Hospital Oldenburg, Department of Anesthesiology, Intensive Care Medicine; Emergency Medicine, and Pain Therapy: Anja Diers, Florian Jelschen, Andreas Weyland; Thüringen-Klinik Pößneck, Department of Anesthesiology and Intensive Care Medicine: Frieder Knebel, Thomas Kupfer; Asklepios Hospital Radeberg, Department of Intensive Care and Emergency Medicine: Rüdinger Sinz; Thüringen-Kliniken Saalfeld, Department of Anesthesiology, Intensive Care Medicine, and Pain Therapy: Petra Bautz, Annemarie Fischer; Ev. Jung-Stilling Hospital Siegen, Department of Anesthesiology, Intensive Care, and Emergency Medicine: Armin Seibel, Christoph Fleischhacker; University Hospital Tübingen; Department of Anesthesiology: Helene Häberle, Philipp Henn, Friederike Mezger, Peter Rosenberger; University Hospital Tübingen; Dept of Internal Medicine: Reimer Riessen, Silvia Ziegler; University Hospital Medical School Ulm, Clinic of Anaesthesiology: Eberhard Barth, Hendrik Bracht, I. Heymann, A. Hinder, R. Sens, Manfred Weiss; Hufeland Hospital Weimar; Department of Anesthesiology and Intensive Care Medicine: Christof Lascho, Henriette Micke, Falk Schmidt; Helios Hospital Wuppertal. Department of Intensive Care Medicine: Stefanie Schilling, Gabriele Wöbker.
Clinical data collection and management
Matthias Löbe, Frank Meineke, Christine Pausch, Christoph Engel (Institute of Medical Informatics, Statistics and Epidemiology, University of Leipzig); statistical support for protocol development: Heike Hoyer (Institute for Medical Statistics, Information, and Documentation: Jena University Hospital); statistical support for implementation of the multiple imputation method: S. Grund, A. Robitzsch (Leibnitz Institute for Science and Mathematics Education, University Kiel).
Compliance with ethical standards
Conflicts of interest
All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr. Bloos reported receiving lecture honoraria from biosyn, Gilead, and CSL Behring. Dr. Harbarth reported receiving personal fees from Johnson & Johnson and Novartis and grants from Pfizer and BioMerieux. Dr. Levy reported receiving grants and personal fees from ImmuneExpress. Prof. Reinhart reported receiving grants and non-financial support from biosyn AG and Thermofischer/BRAHMS, being a shareholder of InflaRx Jena, and receiving personal fees from Adrenomed. Dr. Schuerholz reported grants and personal fees from Astellas Pharma, grants from B Braun Melsungen and Köhler Chemie, personal fees from Bayer Healthcare. Dr. Weyland reported receiving recruitment fees from Jena University Hospital for another trial.
Dr. Bach, Dr. Dey, Dr. Engel, Dr. Gerlach, Dr. Gründling, Dr. Häberle, Dr. Kaisers, Dr. Marshall, C. Matthäus-Krämer, Dr. Meier-Hellmann, Dr. Poidinger, Dr. Riessen, Dr. Rüddel, Dr. Scheer, Dr. Schreiber, D. Schwarzkopf, Dr. Simon, Dr. Thomas-Rüddel, Dr. Weiler, Dr. Weiss, and Dr. Woebker reported no conflicts of interest.
The study was funded by the German Federal Ministry of Education and Research via the integrated research and treatment center “Center for Sepsis Control and Care” (FKZ 01EO1002).
- 4.Gaieski DF, Mikkelsen ME, Band RA et al (2010) Impact of time to antibiotics on survival in patients with severe sepsis or septic shock in whom early goal-directed therapy was initiated in the emergency department. Crit Care Med 38:1045–1053. doi: 10.1097/CCM.0b013e3181cc4824 CrossRefPubMedGoogle Scholar
- 6.Noritomi DT, Ranzani OT, Monteiro MB et al (2014) Implementation of a multifaceted sepsis education program in an emerging country setting: clinical outcomes and cost-effectiveness in a long-term follow-up study. Intensive Care Med 40:182–191. doi: 10.1007/s00134-013-3131-5 CrossRefPubMedGoogle Scholar
- 9.Azuhata T, Kinoshita K, Kawano D et al (2014) Time from admission to initiation of surgery for source control is a critical determinant of survival in patients with gastrointestinal perforation with associated septic shock. Crit Care 18:R87. doi: 10.1186/cc13854 CrossRefPubMedPubMedCentralGoogle Scholar
- 22.van der Veer SN, de Vos MLG, van der Voort PHJ et al (2013) Effect of a multifaceted performance feedback strategy on length of stay compared with benchmark reports alone: a cluster randomized trial in intensive care. Crit Care Med 41:1893–1904. doi: 10.1097/CCM.0b013e31828a31ee CrossRefPubMedGoogle Scholar
- 24.Writing Group for the CHECKLIST-ICU Investigators and the Brazilian Research in Intensive Care Network (BRICNet), Cavalcanti AB, Bozza FA et al (2016) Effect of a quality improvement intervention with daily round checklists, goal setting, and clinician prompting on mortality of critically ill patients: a randomized clinical trial. JAMA 315:1480–1490. doi: 10.1001/jama.2016.3463 CrossRefGoogle Scholar
- 35.Ferrer R, Martin-Loeches I, Phillips G et al (2014) Empiric antibiotic treatment reduces mortality in severe sepsis and septic shock from the first hour: results from a guideline-based performance improvement program. Crit Care Med 42:1749–1755. doi: 10.1097/CCM.0000000000000330 CrossRefPubMedGoogle Scholar