Revised Sepsis Guidelines to Emphasize Best Practices

Dr. Ian Jenkins of the department of medicine at University of California, San Diego, represented the Society of Hospital Medicine on the revision committee, and shared these observations:

Issues with particular resonance to hospitalists include glycemic control and venous thromboembolism prophylaxis.

Recently the ACP and ACCP have issued guidelines that are less enthusiastic about VTE prophy, and indicate no mortality benefit should be expected. The Surviving Sepsis Campaign guidelines committee draft was very enthusiastic about VTE prophy and implied a potential mortality benefit. It clearly endorsed low-molecular-weight heparin over unfractionated heparin as the agent of choice. This requires some thought and caution because it is based on the PROTECT study (in which the dalteparin group had less pulmonary embolism than the UFH group). PROTECT [Prophylaxis of Thromboembolism in Critical Care Trial] enrolled patients without regard to renal function, but many hospitals use enoxaparin instead of dalteparin, and enoxaparin has significantly more renal clearance than does dalteparin.

Additional evolution in the guidelines includes the backing away from intensive insulin therapy to a more cautious approach after the NICE-SUGAR trial, which found an absolute risk increase in mortality of 2.6%, and the subsequent Endocrine Society guidelines, which now advise a target of less than 180 mg/dL instead of less than 110 mg/dL.

Hospitalists also consider stress ulcer prophylaxis on many patients and the draft includes a 2C (weak) recommendation for proton pump inhibitors (PPIs) over H2-blockers for this purpose. Hospitalists should exercise caution particularly for ward patients in whom stress ulcer prophylaxis is rarely needed because PPI may increase pneumonia and Clostridium difficile rates.

Another major development for this is that Xigris is off the market. Hospitalists don't usually give it, but what is remarkable to me is that this once-promoted therapy has been found ineffective and is unavailable. Over time, the recommendations for intensive insulin and to test for adrenal insufficiency with adrenocorticotropic hormone have been reversed, and the target population for stress-dose steroids has shrunk considerably. Changes like this make me wonder if other recommendations (for example, the resuscitation protocol) might evolve as well.

Lastly, many hospitalists would like to further explore the issue of identification of sepsis on the wards for urgent intervention.

Dr. Jenkins said that he had no relevant conflicts of interest.