The Pace, Presentation, and Profile of Community-Acquired Sepsis and Infection

Abstract

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.