Sepsis: the Achilles’ heel of health care

As health care systems look to lower costs and improve patient outcomes, controlling sepsis is a great place to start. Ignoring that opportunity is a huge mistake.

Sepsis is caused by the body’s exuberant response to an infection. It is the No. 1 inpatient hospital expense in the United States, with costs tripling over the last decade to $27 billion. Nearly half of all hospital deaths are caused by sepsis. And the problem is growing — it’s now one of the top five causes of hospitalization in age groups over 18. This is why a comprehensive plan to detect, treat, and prevent sepsis must be an essential pillar of any serious effort to improve care and drive down costs.

When a patient spikes a fever for an unknown reason, doctors usually send blood samples to be cultured. But it can take an enormously long time — up to six days — to get the results. In addition, these cultures miss 35 percent to 50 percent of infections.

Given the possible delay and uncertainty of blood cultures, if a patient is at high risk for sepsis, his or her clinician will immediately prescribe antibiotics. Doctors know that this represents overtreatment, since sepsis can be indistinguishable from other less-serious health concerns. But you can’t guess wrong if you suspect sepsis, because a patient’s risk of dying rises as much as 8 percent per hour if the infection is improperly treated.

If the patient does not respond to the antibiotic and the fever does not break after 12 to 24 hours, clinicians usually switch to a different antibiotic, and then maybe another, and then possibly to an antifungal drug.

Hospitals are getting better at combating sepsis. Doctors and nurses across the country have done incredible work to improve sepsis awareness. They are preventing more sepsis-causing infections before they ever occur, and they are reaching for antibiotics quicker when sepsis is suspected.

Yet advances in sepsis treatment protocols are fueling another massive health care issue: the rise of drug resistance and superbugs. On the individual level, even one exposure to an antimicrobial drug can reduce the therapy’s effectiveness for that same patient later on. The overuse of antibiotics and other antimicrobial drugs also kills beneficial bacteria and microbes, which can weaken the immune system and lead to hospital readmission. On the global level, drug-resistant infections are predicted to kill more than 10 million people per year by 2050.

To solve the sepsis problem, we need a three-pronged solution: continued improvements in hospital processes to prevent sepsis; improved diagnostics to get patients on targeted treatment faster; and development of new antibiotics.

Hospitals need to aggressively pursue sepsis initiatives. Huntsville Hospital in Alabama is one of many hospitals on the leading edge of refining their processes around sepsis. Clinicians at Huntsville went on the offense, catching suspected sepsis cases early, improving protocols and education, and creating clinical teams focused on sepsis. The result was a reduction of sepsis mortality by more than 50 percent and a significant decrease in hospital readmissions.

Improving the detection of sepsis is bounded by the limitations of current diagnostic tools. The current standard of care for diagnosing sepsis has remained the same since the 1930s — the lengthy process of culturing blood to detect infection-causing organisms. Diagnostic companies must provide new breakthrough technologies to minimize the one- to six-day dark period in which clinicians work without strong diagnostic information. Without better diagnostic tools, solutions to improve sepsis care and fight drug resistance will remain on a collision course.

Our team at T2 Biosystems is one of many trying to support hospitals in this effort by developing blood tests that can detect the microbes that cause sepsis within hours, not days, and with more than 90 percent sensitivity. Instead of culturing blood, our tests use magnetic resonance technology to identify microbes directly in blood, a much faster approach.

Finally, we need to develop new drugs to combat sepsis. While antimicrobial resistance limits the effectiveness of many existing drugs, the number of new ones to address this problem have dwindled in recent years. We must accelerate clinical trials to develop and release antimicrobial drugs faster and help clinicians apply the best one to the right patient at the right time.

For too long, combating sepsis has been an unspoken problem in health care, taking lives and driving up costs. With thousands of lives and billions of dollars at stake, it is time to place a greater emphasis on new models for sepsis prevention, detection, and treatment.


Uwe Reinhardt, 80, Dies; a Listened-to Voice on Health Care Policy

Uwe Reinhardt, an economist whose keen, caustic and unconventional insights cast him as what colleagues called a national conscience in policy debates about health care, died on Monday in Princeton, N.J. He was 80.

The cause was sepsis, his wife, Tsung-Mei Cheng, said. He had taught in the economics department at the Woodrow Wilson School of Public and International Affairs at Princeton University since 1968.

Professor Reinhardt helped shape health care deliberations for decades as a prolific contributor to numerous publications, an adviser to White House and congressional policymakers, a member of federal and professional commissions and a consultant and board member, paid and unpaid, for private industry.

“His work was instrumental in advocating some of the reforms embodied in the Affordable Care Act, such as having Medicare pay for performance rather than entirely on a fee-for-service basis,” Professor Janet Currie, the chairwoman of the Princeton economics department, wrote in an email.

Another colleague, Stuart H. Altman, a professor at Brandeis University, wrote, “No one was close to him in terms of impact on how we should think about how a decent health care system should operate.”

In 2015, the Republic of China awarded Professor Reinhardt its Presidential Prize for having devised Taiwan’s single-payer National Health Insurance program. The system now provides virtually the entire population with common benefits and costs 6.6 percent of the nation’s gross domestic product (about one-third the share that the United States spends).

Just last month, he received the 2017 Bipartisan Health Policy Leadership Award from the Alliance for Health Policy, a nonpartisan research and educational group in Washington.

Professor Reinhardt argued that what drove up the singularly high cost of health care in the United States was not the country’s aging population or a surplus of physicians or even Americans’ self-indulgent visits to doctors and hospitals.

“I’m just an immigrant, so maybe I am missing something about the curious American health care system,” he would often say, recalling his childhood in Germany and flight to Canada and apologizing that English was only his second language.

Then he would succinctly answer the cost question by quoting the title of an article he wrote with several colleagues in 2003 for the journal Health Affairs: “It’s the Prices, Stupid.”

What propelled those prices most, he said, was a chaotic market that operates “behind a veil of secrecy.”

That market, he said, is one in which employers “become the sloppiest purchasers of health care anywhere in the world,” as he wrote in the Economix blog in The New York Times in 2013.

It is also defined by the high cost of prescription drugs, he said, and the astronomical amounts that hospitals spend in dealing with a maze of insurers and health maintenance organizations.

“Our hospitals spend twice as much on administration as any hospital anywhere in the world because of all of this complexity,” he told Managed Care magazine in 2013.

If the nation cut the cost of health care administration in half, he said, the savings would be enough to insure everyone.

Professor Reinhardt’s prescription for a more sensible system included imposing penalties on the uninsured so that people would not postpone buying policies until they got sick. That idea, the so-called individual mandate, requiring most people to purchase health insurance, became an integral component of the Affordable Care Act, otherwise known as Obamacare. Republicans in Congress are now seeking to repeal that provision as part of a tax overhaul.

Professor Reinhardt also advocated providing government subsidies so that low-income families could afford mandated insurance, another feature of Obamacare.

His ideal model was the German system in which insurers negotiate with health care providers to set common binding prices in a specific region.

“I believe it is still the best model there is, because it blends a private health care delivery system with universal coverage and social solidarity,” he told The Times in 2009. “It’s inexpensive and equitable. Coverage is portable. You’re never uninsured in Germany. No family goes broke over health care bills.”

Always opinionated, Professor Reinhardt was also unsparing in inflicting his mordant wit on any self-satisfied expert he considered hypocritical or illogical.

“He was a knife twister of the first class,” the health economist Austin Frakt wrote on the blog The Incidental Economist, of which he is an editor in chief. “Should you hold dearly an idea he targeted for systematic dismantling, you would squirm.”

Professor Reinhardt excoriated college students who blamed loneliness for their binge drinking, describing them as “among the most pampered and highly privileged human beings on the planet.” He suggested that before applying for college young people “be required to spend one to two years in a tough job in the real world.”

And when critics complained that doctors were overpaid, he countered that their collective take-home pay amounted to only 10 percent of national health spending. Slicing it by 20 percent, he wrote, “would reduce total national health spending by only 2 percent, in return for a wholly demoralized medical profession to which we so often look to save our lives.

“It strikes me as a poor strategy,” he added.

With near unanimity, colleagues and admirers praised Professor Reinhardt for transforming raw data into moral imperatives.

Senator Bernie Sanders, the Vermont independent who advocates a “Medicare for all” national health care system, wrote in an email, “Uwe Reinhardt was one of the leaders in the effort to make health care a right, not a privilege.”

And Professor Elliott S. Fisher of Dartmouth called Professor Reinhardt “in so many ways the conscience of the U.S. health care system.”

Uwe (pronounced OO-vuh) Ernst Reinhardt was born on Sept. 24, 1937, in the city of Osnabrück in northwest Germany. His father, Wilhelm, was a chemical engineer. His mother, the former Edeltraut Kehne, was a photographer and painter.

He was raised near the Belgian border and the Hürtgen forest, where American and German soldiers engaged in hand-to-hand combat for four months in 1944.

“I could not help but become witness daily to the horrors of war,” Professor Reinhardt wrote in 2003 in a Times Op-Ed article, praising a Marine chaplain for urging soldiers to pray for their enemies ad well as themselves. “Millions of Europeans of my generation, whom many Americans now disparage so contemptuously as pacifists, had a similar experience.”

His exposure to the war so dismayed him that in the mid-1950s, at 18, rather than be drafted into the army and have to salute a German officer in the wake of “the unimaginable atrocities committed by Nazi Germany” years earlier, his wife said, he left the country, setting off for Canada and leaving his parents and four siblings behind.

He landed in Montreal with $90 in his pocket and no Canadian connections. Having had some apprentice training in shipping in Germany, he found work at a shipping company and worked nights parking cars in a parking lot. He always ate oatmeal for breakfast because it was cheap, his wife said, and to make extra money he routinely volunteered to work overtime for co-workers who had families.

After three years, he had saved enough money to enroll, hundreds of miles away, at the University of Saskatchewan in Saskatoon, the cheapest university he knew of, Ms. Cheng said. (Selling his used Chevrolet and beloved guitar helped defray the costs.)

He graduated with a bachelor of commerce degree and went on to Yale, where he received his doctorate. His thesis was titled “An Economic Analysis of Physicians’ Practices.”

In addition to Ms. Cheng, a health policy research analyst at Princeton who is known as May, he is survived by their children, Dirk, Kara and Mark Reinhardt; his sisters, Heide Cermin and Imeltraut Arndt; his brother, Jurgen; and two grandchildren.

Professor Reinhardt joined the Princeton faculty in 1968 as an assistant professor. At his death, he was the James Madison professor of political economy and professor of economics and public affairs at the Woodrow Wilson School.

“He was so inspired a teacher,” said Henry J. Aaron, a senior fellow at the Brookings Institution, the research organization in Washington, “that he could make accounting the most popular course at Princeton.” Among his students was Bill Frist, a surgeon and a former Republican Senate majority leader from Tennessee.

In 2015, Professor Reinhardt humbly — and facetiously — announced that after reflecting on the global economic crisis that had occurred several years earlier, he was calling it quits.

“After the near-collapse of the world’s financial system has shown that we economists really do not know how the world works, I am much too embarrassed to teach economics anymore,” he wrote.

In an interview not long before that, though, he belied any pretense of self-doubt when he was asked whether he was perplexed by the seemingly insolvable challenges of health care economics.

“Have you ever seen a perplexed economist?” Professor Reinhardt replied. “We have an answer for everything.”


Injecting Arthritic Knees Carries Sepsis Risk

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Study identified four risk factors for sepsis after injections for knee pain.

As knee osteoarthritis becomes increasingly prevalent in the aging population, more patients are turning to their physicians for intra-articular injections. But a Chinese retrospective case-control study in Seminars in Arthritis & Rheumatism has underscored several associated risk factors for deep knee infection and chronic low-grade infection, and points to the need for more thorough pre-injection evaluation of patients and stricter training for doctors administering injections.

Foremost among infection risk factors was injection performed by family physicians, which had an odds ratio (OR) of 5.23 (95% CI 2.0-13.67). In addition, a body mass index of ≥ 25 had an OR for infection of 2.3 (95% CI1.1-4.7), and rheumatoid arthritis an OR of 2.61 (95% CI 1.20-5.68). Injection with corticosteroids versus hyaluronic acid had an OR of 3.21 (95% CI 1.63-6.21).

“We underline the importance of the accurate evaluation of clinical history and comorbidities for every IA injection, particularly for patients with obesity and RA and those receiving corticosteroid injections,” wrote Jiying Chen, MD, of People’s Liberation Army General Hospital, Beijing, and colleagues. “Strict training on septic technique is necessary before doctors should perform invasive knee treatments.”

The authors note that post-injection side effects are generally uncommon and mild — approximately 2%-1% per injection — with most complications being injection-site inflammatory reactions such as pain, swelling, and skin or fat atrophy. But though uncommon, deep knee infection can have serious, sometimes life-threatening, consequences, especially with injections on the rise. Chen and associates refer to an epidemiological analysis reporting that in U.S. patients with knee osteoarthritis, over a 5-year period 43.5% of those who eventually underwent total knee arthroplasty were prescribed preoperative intra-articular steroid injections.

The Beijing investigators identified 50 cases of injection-induced knee infection patients undergoing surgery from 2010-2016 and matched them with 250 non-infected controls. The mean age of patients overall was about 67 years and about 65% were female.

There were 21 cases of septic arthritis and 29 cases of chronic low-grade infection, with the former cases showing significantly higher metrics in fever, localized warmth, swelling, resting pain, night pain, limited motion, serum white blood cell counts and C-reactive protein levels.

Patients who developed infection had a slightly higher mean BMI of 26.2 versus 25.2 for controls.

Of those experiencing infection, 60% underwent injection with corticosteroids versus 34.8% of controls, while just 40% had injections of hyaluronic acid versus 65.2% of controls.

In 82% of deep knee infection cases, injection was administered by a general practitioner compared with 43.6% for controls. Just 12% and 6% received injections from an orthopedic surgeon or a rheumatologist, respectively, compared with 28.8% and 27.6%,respectively, for controls.

“This finding suggests that doctors should receive strict training and pass a formal practice exam before they perform invasive knee treatments, such as intra-articular injections,” the authors write.

Bacterial culture determined that Staphylococcus aureus was the by far the most common microorganism in septic arthritis (47.6%), while low-virulence coagulase-negative (CNN) Staphylococcus was most commonly implicated in chronic low-grade infection (31%), followed by Propionibacterium acnes at 24.1%. Other organisms involved in septic arthritis cases were CNN, StreptococcusEnterococcus, and gram-negative bacilli, all at 9.5%.

“These results completely jibe with what we see in our practice,” Bharat Kumar, MD, of the University of Iowa in Iowa City. “They show that injection technique is extremely important, and part of that is training and part of it is practice.”

Kumar advised physicians to observe strict asepsis measures and evaluate patients carefully before giving injections. “Joint infections don’t happen in a vacuum. There are tissue factors in bone to consider, and you have to look carefully at people who have rheumatoid arthritis, are immunosuppressed, or are sick or weak, as they are at increased risk for infection.”

MedPage Today reported a recent study that suggested corticosteroid injections may also hasten cartilage breakdown.

Among the study limitations reported by Chen et al were its small size, single-center location, and retrospective nature, which introduced the possibility of recall bias. In addition, since some patients injected at the study site may have been followed up at an external referral institution, the investigators were not able to identify all cases of post-injection deep knee infection.


The New War On Sepsis

The New War On Sepsis

Dawn Nagel, a nurse at St. Joseph Hospital in Orange, Calif., knew she was going to have a busy day, with more than a dozen patients showing signs of sepsis. They included a 61-year-old mechanic with diabetes. An elderly man recovering from pneumonia. A new mom whose white blood cell count had shot up after she gave birth.

Nagel is among a new breed of nurses devoted to caring for patients with sepsis, a life-threatening condition that occurs when the body’s attempt to fight an infection causes widespread inflammation. She has a clear mission: identify and treat those patients quickly to minimize their chance of death. Nagel administers antibiotics, draws blood for testing, gives fluids and closely monitors her charges — all on a very tight timetable.

“We are the last line of defense,” Nagel said. “We’re here to save lives. If we are not closely monitoring them, they might get sicker and go into organ failure before you know it.”

Sepsis is the leading cause of death in U.S. hospitals, according to Sepsis Alliance, a nationwide advocacy group based in San Diego. More than 1 million people get severe sepsis each year in the U.S, and up to 50 percent of them die from it. It is also one of the most expensive conditions for hospitals to treat, costing $24 billion annually.

Most hospitals in the U.S. have programs aimed at reducing sepsis, but few have designated sepsis nurses and coordinators like St. Joseph’s. That needs to change, said Tom Ahrens, who sits on the advisory board of Sepsis Alliance.

“From a clinical point of view, from a cost point of view, they make a huge impact,” said Ahrens, a research scientist at Barnes-Jewish Hospital in St. Louis.

Research shows aggressive treatment of sepsis can save lives

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Minutes matter when it comes to treating sepsis, the killer condition that most Americans probably have never heard of, and new research shows it’s time they learn.

Sepsis is the body’s out-of-control reaction to an infection. By the time patients realize they’re in trouble, their organs could be shutting down.

New York became the first state to require that hospitals follow aggressive steps when they suspect sepsis is brewing. Researchers examined patients treated there in the past two years and reported Sunday that faster care really is better.

Every additional hour it takes to give antibiotics and perform other key steps increases the odds of death by 4 percent, according to the study reported at an American Thoracic Society meeting and in the New England Journal of Medicine.

That’s not just news for doctors or for other states considering similar rules. Patients also have to reach the hospital in time.

“Know when to ask for help,” said Dr. Christopher Seymour, a critical care specialist at the University of Pittsburgh School of Medicine who led the study. “If they’re not aware of sepsis or know they need help, we can’t save lives.”

The U.S. Centers for Disease Control and Prevention last year began a major campaign to teach people that while sepsis starts with vague symptoms, it’s a medical emergency.

To make sure the doctor doesn’t overlook the possibility, “Ask, ‘Could this be sepsis?'” advised the CDC’s Dr. Lauren Epstein.


Once misleadingly called blood poisoning or a bloodstream infection, sepsis occurs when the body goes into overdrive while fighting an infection, injuring its own tissue. The cascade of inflammation and other damage can lead to shock, amputations, organ failure or death.

It strikes more than 1.5 million people in the United States a year and kills more than 250,000.

Even a minor infection can be the trigger. A recent CDC study found nearly 80 percent of sepsis cases began outside of the hospital, not in patients already hospitalized because they were super-sick or recovering from surgery.



In addition to symptoms of infection, worrisome signs can include shivering, a fever or feeling very cold; clammy or sweaty skin; confusion or disorientation; a rapid heartbeat or pulse; confusion or disorientation; shortness of breath; or simply extreme pain or discomfort.

If you think you have an infection that’s getting worse, seek care immediately, Epstein said.



Doctors have long known that rapidly treating sepsis is important. But there’s been debate over how fast. New York mandated in 2013 that hospitals follow “protocols,” or checklists, of certain steps within three hours, including performing a blood test for infection, checking blood levels of a sepsis marker called lactate, and beginning antibiotics.

Do the steps make a difference? Seymour’s team examined records of nearly 50,000 patients treated at New York hospitals over two years. About 8 in 10 hospitals met the three-hour deadline; some got them done in about an hour. Having those three main steps performed faster was better — a finding that families could use in asking what care a loved one is receiving for suspected sepsis.



Sepsis is most common among people 65 and older, babies, and people with chronic health problems.

But even healthy people can get sepsis, even from minor infections. New York’s rules, known as “Rory’s Regulations,” were enacted after the death of a healthy 12-year-old, Rory Staunton, whose sepsis stemmed from an infected scrape and was initially dismissed by one hospital as a virus.



Illinois last year enacted a similar sepsis mandate. Hospitals in other states, including Ohio and Wisconsin, have formed sepsis care collaborations. Nationally, hospitals are supposed to report to Medicare certain sepsis care steps. In New York, Rory’s parents set up a foundation to push for standard sepsis care in all states.

“Every family or loved one who goes into a hospital, no matter what state, needs to know it’s not the luck of the draw” whether they’ll receive evidence-based care, said Rory’s father, Ciaran Staunton.

Sepsis Tops Conditions Tracked for Readmission Rates, but Triggers No Penalties

Sepsis Tops Conditions Tracked for Readmission Rates, but Triggers No Penalties

Sepsis has a higher rate of readmission than heart failure, but the federal government does not penalize hospitals for excessive readmissions due to sepsis.

Superbug infection kills patient in Reno

A superbug infection resistant to all 27 available antibiotics killed a woman in Reno, Nevada, the Centers for Disease Control and Prevention reported Friday, in issuing a precaution to hospitals nationwide.

While this superbug case was rare, sepsis blood infections reportedly kill an estimated 258,000 Americans each year.

Medical experts have been warning for years of the dangers of overprescribing antibiotics because of the potential for antibiotic-resistant superbugs.

The female patient who died this September from the superbug infection was a Washoe County, Nevada resident in her 70s who arrived in the United States in early August 2016 after an extended visit to India, the CDC said.

On August 18, she was admitted to an acute care hospital with a primary diagnosis of an infection called systemic inflammatory response syndrome, which likely resulted from an infected right hip.

A week after she was admitted, the hospital notified the Washoe County Health District in Nevada that the patient had a bacterial infection of carbapenem-resistant Enterobacteriaceae, called CRE.