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A retrospective cohort study. Studies to quantify the breadth of antibiotic exposure across populations remain limited. Therefore, we applied a validated method to describe the breadth of antimicrobial coverage in a multicenter cohort of patients with suspected infection and sepsis. We conducted a retrospective cohort study across 21 hospitals within an integrated healthcare delivery system of patients admitted to the hospital through the ED with suspected infection or sepsis and receiving antibiotics during hospitalization from January 1, 2012, to December 31, 2017. We quantified the breadth of antimicrobial coverage using the Spectrum Score, a numerical score from 0 to 64, in patients with suspected infection and sepsis using electronic health record data. Of 364,506 hospital admissions through the emergency department, we identified 159,004 (43.6%) with suspected infection and 205,502 (56.4%) with sepsis. Inpatient mortality was higher among those with sepsis compared to those with suspected infection (8.4% vs 1.2%; P < .001). Patients with sepsis had higher median global Spectrum Scores (43.8 [interquartile range IQR 32.0–49.5] vs 43.5 [IQR 26.8–47.2]; P < .001) and additive Spectrum Scores (114.0 [IQR 57.0–204.5] vs 87.5 [IQR 45.0–144.8]; P < .001) compared to those with suspected infection. Increased Spectrum Scores were associated with inpatient mortality, even after covariate adjustments (adjusted odds ratio per 10-point increase in Spectrum Score 1.31; 95%CI 1.29–1.33). Spectrum Scores quantify the variability in antibiotic breadth among individual patients, between suspected infection and sepsis populations, over the course of hospitalization, and across infection sources. They may play a key role in quantifying the variation in antibiotic prescribing in patients with suspected infection and sepsis.

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Rationale: Sepsis is life-threatening organ dysfunction that accompanies progressive, severe infection. Despite the global impact of sepsis, little is known about the symptoms that precede this progression of simple infection into sepsis. Methods: We evaluated suspected infection (SI) and Sepsis-3 (S3) patients who presented through the emergency department (ED) and were hospitalized in a Northern California health system between 2012 and 2017. To identify the pre-hospital symptoms and signs of sepsis and infection, we applied natural language processing (NLP) to specific segments of free-text physician documentation (e.g., history and physical notes, ED provider notes) within the first 24 hours using SNOMED and NCI ontologies. We aggregated similar symptoms and signs within 245 categories, for example, combining shortness of breath and dyspnea. We compared symptoms in infection to those present in heart failure and stroke patients. We further estimated the elapsed symptom duration prior to hospital presentation and evaluated which symptoms were most strongly associated with adverse outcomes including hospital mortality, intensive care unit (ICU) need, and increased length of stay (LOS). Results: During the study period, we identified 408,362 mutually exclusive ED-onset hospitalizations for sepsis-3 (S3; 204,196), suspected infection (SI; 159,286), heart failure (HF; 24,581) and stroke (19,121). Overall mortality was 8.4% (S3), 1.2% (SI), 4.9% (HF), and 4.9% (stroke). In total, we extracted >6 million free text segments with a median of 13 positive symptom segments per SI/S3 hospitalization. The 5 most frequent symptoms in sepsis were: fever (34.0%), pain (29.1%), altered mentation (27.1%), dyspnea (26.7%), and weakness (23.2%). In suspected infection, they were: pain (18.3%), fever (17.0%), dyspnea (11.8%), cough (11.2%), and nausea (11.0%). In heart failure, the top 5 symptoms were: dyspnea, edema, cough, orthopnea, and chest pain. In stroke, they were: weakness, altered mentation, dysarthria, facial droop, and hypertension. The shortest median pre-ED symptom duration in sepsis were fever, chills, and altered mentation (2 days). Sepsis symptoms most strongly associated with death were: cardiac arrest, hypothermia, hypotension/shock, liver failure, and pneumothorax (Figure). Symptoms most strongly associated with ICU care were: cardiac arrest, shock, myocardial infarction, gastrointestinal bleeding, and hyperglycemia. Symptoms strongly associated with prolonged hospitalization were: brain injury, cardiac arrest, bowel obstruction, wound infection, and hypothermia. Conclusions: Patients with sepsis and suspected infection were clearly different from patients with other conditions in their pace, profile, and presentation. High-risk profiles can be used to enhance current public awareness of sepsis as well as improve clinician diagnostic excellence.