Sepsis, November 1 edition

In 327 adults triggering a sepsis alert, early direct communication with the on-call microbiologist was associated with higher rates of etiologic diagnosis within 24 hours after adjustment for clinical factors. Early microbiology activation was also associated with more frequent use of rapid diagnostic techniques and earlier antimicrobial de-escalation, but it did not improve mortality, intensive care admission, or hospital length of stay.

Impact: This study identifies a relatively simple, organization-level intervention that can accelerate microbiological diagnosis and antimicrobial optimization without requiring a new diagnostic technology. Its adjusted analysis supports implementation research in diagnostic stewardship, while the absence of mortality benefit appropriately limits causal claims.

Clinical Implications: Hospitals may consider embedding direct microbiologist notification into sepsis alert pathways, particularly where rapid diagnostic testing and antimicrobial stewardship resources are available. The intervention should be evaluated locally because the study was conducted at a single tertiary-care center and did not demonstrate improved patient-centered outcomes.

Future Directions: Multicenter stepped-wedge or cluster-randomized implementation studies should test whether early microbiology activation improves antibiotic appropriateness, adverse drug events, resistance selection, and clinical outcomes. Future work should also define staffing requirements, response-time targets, and cost-effectiveness.

This systematic review included 18 real-world cohorts and quantitatively synthesized 11, using DPP-4 inhibitors as an active comparator and applying ROBINS-I and GRADE. For incident sepsis, the exploratory pooled estimate favored SGLT2 inhibitors, but the prediction interval crossed the null, heterogeneity was substantial, and certainty was very low; therefore, the findings do not support a preventive effect or a causal reduction in severe infection.

Impact: The study is important because it addresses a clinically relevant medication-safety question while explicitly separating association from causation. Its use of active comparators, prediction intervals, leave-one-out analyses, and GRADE prevents potentially reassuring observational associations from being overstated as infection-preventive effects.

Clinical Implications: SGLT2 inhibitors should not be prescribed specifically to prevent sepsis or severe infection on the basis of current observational evidence. Treatment decisions should continue to prioritize established cardiovascular, renal, and glycemic indications, while clinicians remain attentive to infection-related complications in high-risk patients.

Future Directions: Future studies should use target-trial emulation, new-user active-comparator designs, detailed adjustment for infection risk and diabetes severity, and consistent sepsis definitions. Randomized trial data and individual-participant-data meta-analysis would help clarify whether any apparent association reflects residual confounding or a true drug effect.

In this prospective diagnostic accuracy study of 80 adults with new-onset septic and/or hypovolemic shock, baseline corrected carotid flow time and its change after a fluid bolus poorly discriminated echocardiography-defined fluid responders. The findings provide a clinically useful negative validation: corrected carotid flow time should not be relied on alone to guide fluid resuscitation in this population.

Impact: The study directly tests a convenient, non-invasive bedside metric that could otherwise encourage inappropriate fluid administration. Its negative findings are clinically important because they discourage reliance on a poorly discriminative measure and reinforce the need for validated multimodal assessment of fluid responsiveness.

Clinical Implications: Clinicians should not use baseline corrected carotid flow time or its post-bolus change as the sole determinant of fluid administration in septic or hypovolemic shock. Assessment should incorporate clinical context, dynamic tests with validated thresholds, echocardiography, perfusion markers, and close monitoring for recurrent hypotension or fluid-related harm.

Future Directions: Larger multicenter diagnostic studies should stratify septic and hypovolemic shock, standardize Doppler acquisition, assess interobserver reliability, and compare corrected carotid flow time with validated dynamic tests such as passive leg raising combined with direct cardiac-output measurement. Studies should also determine whether it adds value within multimodal algorithms rather than as a stand-alone test.