Attributable mortality due to nosocomial sepsis in Brazilian hospitals: a case–control study
Authors: Zampieri Fernando G. , Cavalcanti Alexandre B. , Taniguchi Leandro U. , Lisboa Thiago C. , Serpa-Neto Ary , Azevedo Luciano C. P. , Nassar Antonio Paulo , Miranda Tamiris A. , Gomes Samara P. C. , de Alencar Filho Meton S. , da Silva Rodrigo T. Amancio , Lacerda Fabio Holanda , Veiga Viviane Cordeiro , de Oliveira Manoel Airton Leonardo , Biondi Rodrigo S. , Maia Israel S. , Lovato Wilson J. , de Oliveira Claudio Dornas , Pizzol Felipe Dal , Filho Milton Caldeira , Amendola Cristina P. , Westphal Glauco A. , Figueiredo Rodrigo C. , Caser Eliana B. , de Figueiredo Lanese M. , de Freitas Flávio Geraldo R. , Fernandes Sergio S. , Gobatto Andre Luiz N. , Paranhos Jorge Luiz R. , de Melo Rodrigo Morel V. , Sousa Michelle T. , de Almeida Guacyra Margarita B. , Ferronatto Bianca R. , Ferreira Denise M. , Ramos Fernando J. S. , Thompson Marlus M. , Grion Cintia M. C. , Santos Renato Hideo Nakagawa , Damiani Lucas P. , Machado Flavia R. ,   for the MAPA investigators, the BRICNet, Macedo Barbara , Coutinho Fabio S. , Arraes Jussara A. , Xavier Viviane S. N. , Martins Eliana V. N. , Coelho Juliana Chaves , Santos Silvana S. , Pardini Andreia , Zandonai Cassio Luis , de Carvalho Julia B. , Louredo Isabela O. B. , Gonçalves Renata C. , Arruda Micheli C. , da Cunha Mariana Regina , de Almeida Mariana Bonomini F. , Ramos Juliano , Binda Bruna M. , Almeida Priscila L. S. , de Oliveira Marcia Maria R. , de Mattos Luciana S. , da Silva Samara G. , Dorta Daniela C. , Hadrich Martha , Gonçalves Fernanda A. F. , de Sena Kaytiussia R. , dos Prazeres Pamella M. , Festti Josiane 
Published: April 2023

Abstract
Background
Nosocomial sepsis is a major healthcare issue, but there are few data on estimates of its attributable mortality. We aimed to estimate attributable mortality fraction (AF) due to nosocomial sepsis.

Methods
Matched 1:1 case–control study in 37 hospitals in Brazil. Hospitalized patients in participating hospitals were included. Cases were hospital non-survivors and controls were hospital survivors, which were matched by admission type and date of discharge. Exposure was defined as occurrence of nosocomial sepsis, defined as antibiotic prescription plus presence of organ dysfunction attributed to sepsis without an alternative reason for organ failure; alternative definitions were explored. Main outcome measurement was nosocomial sepsis-attributable fractions, estimated using inversed-weight probabilities methods using generalized mixed model considering time-dependency of sepsis occurrence.

Results
3588 patients from 37 hospitals were included. Mean age was 63 years and 48.8% were female at birth. 470 sepsis episodes occurred in 388 patients (311 in cases and 77 in control group), with pneumonia being the most common source of infection (44.3%). Average AF for sepsis mortality was 0.076 (95% CI 0.068–0.084) for medical admissions; 0.043 (95% CI 0.032–0.055) for elective surgical admissions; and 0.036 (95% CI 0.017–0.055) for emergency surgeries. In a time-dependent analysis, AF for sepsis rose linearly for medical admissions, reaching close to 0.12 on day 28; AF plateaued earlier for other admission types (0.04 for elective surgery and 0.07 for urgent surgery). Alternative sepsis definitions yield different estimates.

Conclusion
The impact of nosocomial sepsis on outcome is more pronounced in medical admissions and tends to increase over time. The results, however, are sensitive to sepsis definitions.