The impact of delayed source control and antimicrobial therapy in 196 patients with cholecystitis-associated septic shock
CCCF ePoster library. Dong V. Oct 4, 2017; 198139; 100
Victor Dong
Victor Dong
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The impact of delayed source control and antimicrobial therapy in 196 patients with cholecystitis-associated septic shock

Dong, Victor1;Karvellas, Constantine1, 2 ;Abraldes, Juan G1; Kumar, Anand3, 4 

  1. Division of Gastroenterology and Hepatology, University of Alberta, Edmonton, Canada.

  2. Division of Critical Care Medicine and Gastroenterology/Hepatology, University of Alberta, Edmonton, AB Canada.

  3. Section of Critical Care Medicine, University of Manitoba, Winnipeg, Canada.

  4. Section of Infectious Diseases, University of Manitoba, Winnipeg, Canada. 

Background: Cholecystitis-associated septic shock carries significant mortality. Treatment includes early administration of antimicrobial therapy along with source control (cholecystectomy or percutaneous cholecystostomy drainage). There is uncertainty regarding the most appropriate time to achieve source control. Our aim was to determine whether timing of source control affects survival in cholecystitis patients with septic shock.
Methods: Nested retrospective cohort study of all cholecystitis-associated septic shock patients (met Tokyo guidelines for cholecystitis along with hypotension requiring vasopressors) from an international, multicenter database between 1996 and 2015. Multivariate logistic regression analysis was performed to determine associations between practice related factors (delay to source control and antibiotics) and severity of illness on in-hospital mortality. Classification and regression tree (CART) analysis was used to evaluate the interaction between non-linear covariates.
Results: Among 196 patients (mean age 69 years, 70% male), overall mortality was 37%. Compared to non-survivors (n=72), survivors (n=124) had lower mean admission Acute Physiology and Chronic Health Evaluation (APACHE) II scores (21 vs. 27, p<0.001) and lower median admission serum lactate (2.4 vs. 6.8 µmol/L, p<0.001). Survivors were more likely to receive appropriate antimicrobial therapy earlier (median 2.8 vs. 6.1 hours from shock, p=0.012). Survivors were also more likely to undergo successful source control earlier (median 9.8 vs. 24.7 hours, p<0.001). Adjusting for covariates, APACHEII [Odds ratio (OR) 1.13 (95% CI 1.06-1.21) per increment] and delayed source control >16 hours [OR 4.45 (1.88-10.70)] were independently associated with increased mortality (p<0.001 for all; c-statistic 0.800). CART analysis demonstrated patients with APACHEII of 15 to 26 benefitted most from source control within 16 hours (p<0.0001).
Conclusions: Patients with cholecystitis-associated septic shock have significant mortality. Admission APACHEII score and delay in source control >16 hours significantly affected hospital outcomes. This suggests urgent source control (within 16 hours) could improve outcomes in high-risk patients.

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