this explanation Conversely, overall hospital mortality only decreased by around 10% over the same period, after initial ICU stays of 15.2 days on average in the report by Annane et al. [3]versus 9 days in our study. This suggests that despite earlier recognition and management, with likely more appropriate therapy, the effectiveness of post-ICU care of septic shock patients remains suboptimal [44]. It is possible that certain patients expressed their desire not to be resuscitated or re-admitted to ICU, or that a decision to limit or withdraw therapy may have been made by physicians. Such factors could also explain the reduced mortality benefit that we observed during the ICU stay. Padkin et al. reported post-ICU mortality of 12.3%, corresponding to 18% of patients discharged alive from the ICU but who subsequently died before being discharged from the hospital [36].

Inappropriately early discharge [45] or discharge to an unsuitable follow-up ward because of excessive workload could also be contributing factors [45,46].The independent prognostic factors for time to mortality right censored at day 28 identified in our study were age, immunosuppression, SOFA score, and Knaus score C/D. Conversely, we observed that urinary tract infection as the origin of sepsis had a protective effect. In a similar population, Annane et al. showed that age, severity of illness, characteristics of infection, and life-support therapy were associated with ICU mortality [3]. However, in our study, life-support therapy was not included in the multivariate analysis, as it is a time-dependent variable with no adjustment for the updated SOFA value, and this could introduce an indication bias.

The prognostic factors for death in septic shock patients reported in the literature vary widely according to the type of statistical analysis (uni- or multivariate), the primary endpoint (28-day, ICU, or in-hospital mortality), and the inclusion criteria of the studies.The rate of documented infection varies from 52% to 90% in the literature, while in our study infection with an identified microorganism was documented in nearly 60% of septic shock cases. As regards the site of infection responsible for septic shock, the most common locations were pulmonary (48.5%), abdominal (17.6%), and urinary tract (9.5%), as reported in previous studies [3,6,8,16,47].

Our results show that Carfilzomib gram-negative organisms currently account for a majority of infections, as reported in other studies [6,8,16]. However, in our study, we did not observe the germ responsible for infection to be associated with 28-day mortality. This corroborates findings from another recent French study that included over 4,000 episodes of severe sepsis in 3,588 patients [48].Early appropriate antibiotic therapy is of capital importance in the management of sepsis, as reported by several authors [40,49].