Regional adherence to early sepsis management bundle and associated mortality in Hong Kong between 2009-2018

Background Longitudinal data on sepsis bundle adherence and associated survival at a country or regional level is scarce. Methods 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. All adult hospitalizations for community-acquired sepsis (CAS) at 41 publicly-funded hospitals in Hong Kong between 2009-2018 were included. Generalized estimating equations were used to assess association between full bundle adherence and its individual elements with hospital mortality. Results Amongst 421,096 CAS, full bundle adherence rate increased from 0.2% in 2009 to 1.2% in 2018 (relative+18.9%/year, P<0.001), with limited uptake of each individual element. Relative increase in empirical broad-spectrum antibiotics administration (+9.8%/year [95%CI:8.3%-11.2%]) was faster than AMR prevalence (+5.2%/year [95%CI:3.6%-6.9%]). Full bundle adherence was associated with reduced mortality (ORadj 0.75 [95%CI:0.65-0.86]). Blood culture collection was associated with reduced mortality (ORadj 0.88 [95%CI:0.83-0.93]); whilst lactate measurement was only associated with reduced mortality in septic shock (ORadj 0.85 [95%CI:0.76-0.94]). Broad-spectrum antibiotics was associated with reduced mortality (ORadj 0.73 [95%CI:0.56-0.96]) when used appropriately in bacteremia from ESBL pathogens or MRSA. Conclusions 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 only associated with better survival if used appropriately. Efforts should focus not only on ensuring bundle adherence, but also on prioritizing the right treatments for the right patients.