Regional Adherence to Early Sepsis Management Bundle and Associated Mortality in Hong Kong Between 2009-2018

Longitudinal data are scarce on sepsis bundle adherence and associated survival at a country or regional level.

A population-based electronic health record database was leveraged to determine temporal trends in sepsis bundle adherence (empirical broad-spectrum antibiotic administration, blood culture collection, lactate measurement) on sepsis onset day and antimicrobial resistance (AMR) prevalence. This study included all adult hospitalizations for community-acquired sepsis at 41 publicly funded hospitals in Hong Kong between 2009 and 2018. Generalized estimating equations were used to assess the association between full bundle adherence and its individual elements with hospital mortality.

Among 421 096 cases of community-acquired sepsis, the full bundle adherence rate increased from 0.2% in 2009 to 1.2% in 2018 (relative +18.9%/y, P < .001), with limited uptake of each element. The relative increase in empirical broad-spectrum antibiotics administration (+9.8%/y [95% CI, 8.3%-11.2%]) was faster than the AMR prevalence (+5.2%/y [95% CI, 3.6%-6.9%]). Full bundle adherence was associated with reduced mortality (adjusted odds ratio [OR_adj], 0.75 [95% CI, .65-.86]). Blood culture collection was associated with reduced mortality (OR_adj, 0.88 [95% CI, .83-.93]), while lactate measurement was associated only with reduced mortality in septic shock (OR_adj, 0.85 [95% CI, .76-.94]). Broad-spectrum antibiotics was associated with reduced mortality (OR_adj, 0.73 [95% CI, .56-.96]) when used appropriately in bacteremia from extended-spectrum beta-lactamase pathogens or methicillin-resistant Staphylococcus aureus.

Basic sepsis care implementation remains challenging even in high-income settings. Empirical broad-spectrum antibiotic usage has outpaced AMR risk. Full sepsis bundle adherence was associated with improved survival, but empirical broad-spectrum antibiotics was associated with better survival only if used appropriately. Efforts should focus not only on ensuring bundle adherence but also on prioritizing the right treatments for the right patients.