Title:Bloodstream infections and sepsis in Greece: over-time change of epidemiology and impact of de-escalation on final outcome

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1 Author's response to reviews Title:Bloodstream infections and sepsis in Greece: over-time change of epidemiology and impact of de-escalation on final outcome Authors: Marina Koupetori Theodoros Retsas Nikolaos Antonakos Glykeria Vlachogiannis Ioannis Perdios Christos Nathanail Konstantinos Makaritsis Antonios Papadopoulos Dimitrios Sinapidis Evangelos J Giamarellos-Bourboulis (egiamarel@med.uoa.gr) Ioannis Pneumatikos (ipnevmat@med.duth.gr) Charalambos Gogos (cgogos@med.upatras.gr) Apostolos Armaganidis (aarmag@med.uoa.gr) Elisabeth Paramythiotou (lparamyth61@hotmail.com) Version:2Date:9 May 2014 Author's response to reviews: see over

2 REVIEWER 1 Dr. Koupetoni et al compared the sepsis epidemiology in Greece during two different periods and found some differences in the epidemiology of communityacquired sepsis epidemiology (but not in the nosocomial sepsis epidemiology). The study is a further analysis of parameters included in the database of a national sepsis network. The findings as summarized in the first paragraph of Discussion are of local importance but they re-emphasize some interesting aspects of epidemiology and sepsis management. From this aspect, they may be interesting to the readership of the Journal. Page 2, Conclusion. The statement about the financial crisis is not a conclusion of this study. Should not be mentioned here. The other two statements of the conclusions are selfevident and expected findings. Reply: This conclusion was deleted, as suggested. Page 4, last para. The hypothesis that financial health restraint hampers management of sepsis in an environment with antibiotic overconsumption is probably not correct. Use of fewer and less expensive (broad spectrum) antibiotics due to the financial crisis would probably decrease the antibiotic pressure and the resistance. This argument and conclusion should be deleted from the manuscript since it is not proven by any kind of economic analysis. Reply: We agree with this reviewer that presented data and type of analysis cannot provide robust evidence on the impact of the financial crisis on the management of sepsis. Referral to this has been thoroughly deleted from the revised manuscript. Table 1 consists of a univariate analysis. Since a number of confounding factors may inter-relate some of these parameters, a multivariate analysis should be performed in order to substantiate the findings of the authors, ie that Type 2 diabetes mellitus is more in the second period in the patients who presented to the ER with sepsis, etc.

3 2 Reply: The manuscript now reads on pg8, ln27-29: Logistic regression analysis of these changes revealed that increase of type 2 diabetes mellitus was the main difference between the two study periods (Table 2). A new Table, namely Table 2, has been added with the suggested logistic regression analysis of the univariate analysis of the findings of Table 1. Consecutive enumeration of the remaining Tables was changed appropriately. Figure 1. What was the definition of sepsis? From this figure, it seems that only about a fourth of sepsis cases were defined as BSI? What were all the other three fourth of the cases? Clinical sepsis, or what? Reply: Selection was based on patients with at least two criteria of SIRS and microbiologically or clinical documented infection. This has now been added in the revised Figure 1. Minor revisions: Page 2, end of 2nd paragraph. of antimicrobial therapy should be on antimicrobial therapy. Page 4, 2nd paragraph. in the aim is not needed. Reply: These changes were done, as suggested. Page 5. Neutropenia <1000 was excluded. The authors mean malignancyrelated neutropenia. Did they also exclude those who had sepsis-related neutropenia? Reply: This exclusion criterion has now been modified on pg5, ln20-21 of the revised manuscript as neutropenia defined as less than 1000 neutrophils/mm 3 due to causes other than sepsis. REVIEWER 2 The English is generally acceptable, but could be improved in places; review by someone with English as their 1st language or who is highly fluent would improve readability

4 3 Reply: All effort was done to improve English writing 754 patients from so many centres over 3 years seems a surprisingly small number of bacteraemias - my own centre (1400 bed teaching hospital) gets this number in 1 year of which about half are Gram negatives alone - were the patients included consecutive? Were all patients included (i.e. the wholepopulation)? Either way, please clarify this in the manuscript. Reply: The manuscript now reads on pg5, ln14-15 Participating departments were not obliged to report all cases of sepsis admitted since the beginning of the study. I'm a bit confused about why only community-acquired bacteraemias managed in general wards and those with hospital-acquired bacteraemias in the ICU were included. What about hospital-acquired bacteraemias in general wards. What about community-acquired bacteraemias admitted directly to the ICU? Could you please clarify and justify why this approach was taken and (if this is the case) why other groups were left out. Reply: The manuscript now reads on pg5, ln12-14: Patients with communityacquired sepsis admitted to the general ward or with hospital-acquired sepsis developing in the ICU at least 48 hours after ICU admission are enrolled in this study. In the cox-regression analysis on P8, were other patient characteristics, such as age, sex, etc. included? If not, why? Age is an important determinant of outcome. Reply: Cox regression analysis was repeated and age and gender were studied in the equation as stated on pg8, ln2 of the revised manuscript. Results are provided on the revised Figure 6.

5 4 Did the total number of hospital admissions and/or the total number of blood cultures taken change between the two time periods; this is important to fully understand the results. Reply: The manuscript now reads on pg8, ln9-12. Blood sampling was done prior to administration of the first dose of empirical antimicrobial therapy in 773 out of 1814 patients (42.9%) screened during the study period and in 748 out of 1292 patients (57.9%) screened during the study period (p< between the two study periods). What is meant by "chronic hemodilution" - please define. Reply: This was changed into chronic hemofiltration throughout the revised manuscript. How was previous exposure to antibiotic therapy established? Please state. Reply: The manuscript now reads on pg6, ln16-18: Prior exposure to an antimicrobial agent was elaborated both by the patients case history and by monitoring of the prescribed drugs over the last three months. There appears to have been a decrease in the proportion of patients deescalated in the second period; why do you think this occurred? It would be worth discussing this in the discussion section. Reply: The manuscript now reads on pg12, ln23-28: However, the proportion of patients de-escalated in the second study period was decreased compared with the first study period. The study was not interventional for the implementation of the de-escalation but this was a choice of the attending physicians. It may be hypothesized that the decrease of proportion of de-escalated patients may be linked with a feeling of physicians that antimicrobial resistance increase over-time and a subsequent fear for the de-escalation strategy.

6 5 You often use the word "incidence", but no true incidences are presented; simply numbers and proportions. One needs to know the number in the entire population to calculate an incidence. Please rephrase appropriately. Reply: Rephrasing was done throughout the manuscript, as suggested I am not at all convinced that this study provides any evidence that the results were influenced by the financial crisis - it is tempting to think this and I'm sure it has impacted on health in Greece, but without an adequate control group the evidence and crude statistical analyses upon which such statements are based are weak. It is equally possibly that more patients with diabetes were admitted simply by chance and it is this that drove the increased severity or that it reflects the ongoing and worsening global obesity/diabetes epidemic, etc. I would remove the "caused by the financial crisis" aspect of this manuscript and concentrate on the microbial epidemiology. Reply: We agree with this reviewer that presented data and type of analysis cannot provide robust evidence on the impact of the financial crisis on management of sepsis. Referral to this has been thoroughly deleted from the revised manuscript. In the manuscript, you do not explicitly state what proportion of Gram negatives were ESBL or KPC producers; please present this if the data is available to you. Reply: This information is now provided on pg9, ln11-15 and on pg12, ln7-11 of the revised manuscript. Minor It would be useful to state in the abstract that this is a multi-centre study. Reply: This was done on pg3, ln7 of the revised manuscript, as suggested.

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