A Multicenter Study in Northern Italy to Evaluate the Impact of a Sepsis Bundle in Obstetric Settings: The SOS Study

Abstract

Background: In 2018, Lombardy's Fight Against Sepsis in Obstetrics group developed a regional sepsis management bundle for obstetric patients. This study aimed to evaluate the impact of this bundle on maternal and neonatal clinical outcomes and on process measures.

Methods: This multicenter, observational, retrospective study included data from pregnant and puerperal adult patients diagnosed with sepsis according to the Surviving Sepsis Campaign guidelines in 2 periods: May 2015 to May 2018 (prebundle) and July 2018 to January 2023 (postbundle).

Results: Eighty women were included: 24 (30.0%) in the prebundle period and 56 (70.0%) in the postbundle period. The primary source of infection was urinary (40.0%), with Escherichia coli being the most common pathogen isolated from blood cultures. Regarding clinical outcomes, no deaths occurred in pre- and postbundle periods. For mothers, there was no significant difference in median length of stay between the groups, while neonatal intensive care unit admissions of neonates significantly decreased from 85.7% to 31.3% (P = .013). Regarding process measures, the only significant increase occurred in infectious disease specialist consultations in the postbundle period (75.0%) as compared with the prebundle period (50.0%, P = .029).

Conclusions: The implementation of a regional maternal sepsis management bundle did not significantly alter maternal outcomes but was associated with a reduction in neonatal intensive care unit admissions, although what role bundle implementation had in this change remains uncertain. More infectious disease consultations postbundle highlight the potential role of the bundle increasing sepsis awareness among physicians dealing with these patients.

Keywords: bundle; maternal sepsis; neonatal health; pregnancy; puerperium.

Figure 1.

Definition of risk zone based on the Modified Early Obstetric Warning Score (MEOWS) and the modified Sequential Organ Failure Assessment (mSOFA). The image is the modified English version of a flowchart included in the “Operational Guidance Document for Early Identification and Management of Sepsis in Obstetrics” (supplementary materials, attachment 1). The Sepsis Six consists of 3 diagnostic and 3 therapeutic steps—all to be delivered within 1 hour of the initial diagnosis of sepsis:1. Deliver high-flow oxygen.2. Take blood cultures and consider source control.3. Administer empiric intravenous antibiotics.4. Measure serial serum lactates and send full blood count.5. Start intravenous fluid resuscitation.6. Commence accurate urine output measurement [10].

Figure 2.

Flowchart of study population.