Postoperative Sepsis Rates and Severity Increased : The rates of postoperative sepsis, and especially severe sepsis, rose significantly over a 17-year period.

The rate of postoperative sepsis among adult patients increased significantly over a 17-year period, as did the proportion of cases that were considered severe, according to an analysis of a state inpatient database.

Although hospital mortality from postoperative sepsis dropped in patients undergoing nonelective surgery, the proportion of patients who developed severe sepsis after elective surgery increased significantly, and mortality from sepsis after elective surgery did not improve, Dr. Todd Vogel said. He presented results of the study at the annual meeting of the Surgical Infection Society.

“What's concerning from the data is that elective cases did not show a significant decreased trend at all; in fact, we have not made any headway in mortality secondary to sepsis” after elective surgery, said Dr. Vogel, of the University of Medicine and Dentistry of New Jersey, Robert Wood Johnson Medical School, New Brunswick.

Dr. Vogel and his associates analyzed data from the State Inpatient Database for New Jersey from 1990 to 2006 for patients aged 18 and older who developed sepsis after elective or nonelective surgery, using diagnosis codes defined by the Agency for Healthcare Research and Quality. There were 1,276,451 surgery discharges during that time, of which 42% were elective and 58% were nonelective. Sepsis was a complication in 3% of all surgical procedures.

Of the patients undergoing elective surgery, about 1% developed postoperative sepsis and 0.5% developed severe sepsis (defined as sepsis complicated by organ dysfunction). The rate of sepsis after elective surgery increased from 0.67% to 1.74%, and the rate of severe sepsis increased from 0.22% to 1.12%. Both were highly statistically significant increases. The proportion of sepsis cases that were severe after elective surgery nearly doubled from 33% to 65%, also a highly significant increase.

The rates of postoperative sepsis and severe sepsis were significantly higher among the patients who had nonelective surgery (about 4% for sepsis and about 2% for severe sepsis). The rate of sepsis after nonelective surgical procedures increased from 3.7% to 4.5%, and the rate of severe sepsis increased from 1.8% to about 3%. The proportion of sepsis cases after nonelective surgery that were severe increased significantly from almost 48% to nearly 70%. However, in-hospital mortality among these patients dropped from 38% to 30% for sepsis and from 55% to 38% for severe sepsis, a highly significant decrease.

The pattern of pathogens also changed during the period studied, with a significant drop in rates of septicemia caused by staphylococci, anaerobes, pseudomonas, and Escherichia coli among the nonelective surgery cohort. There was also a significant increase in the rates of streptococcal septicemia and staphylococcal septicemia in a subgroup of patients undergoing elective surgery, but the rates of septicemia caused by E. coli, pseudomonas, and anaerobes remained unchanged in this cohort.

The findings may be explained by changes in the types of patients who are admitted to the hospital for elective surgery, Dr. Vogel said in an interview. The trend toward minimally invasive procedures may mean that elderly patients or those who are sicker are more likely to be admitted to the hospital for elective surgery, he speculated. The improved mortality among nonelective cases could be attributable to advances in critical care and antibiotics, and greater awareness of sepsis, he added, noting that this was not clear from the data and will be the focus of a future study.

The investigators also found a significant disparity based on ethnicity, gender, and age of patients, which Dr. Vogel said needs to be studied further. The rates of postoperative sepsis and mortality after nonelective and elective surgery were highest among black patients, compared with white patients (who had the lowest rates) and Hispanic patients. Men were more likely to have postoperative sepsis than were women, and there was a significant increase in the rates of postoperative sepsis with age.