Early Recognition and Treatment of Sepsis and Its Impact on Mortality and ICU Outcomes: A Retrospective Cohort Study from Gaza, Palestine

Abstract

Sepsis remains a leading cause of intensive care unit (ICU) admission and in-hospital mortality worldwide, with a disproportionately high burden in low-resource and conflict-affected settings. Early recognition and timely initiation of evidence-based management—particularly antimicrobial therapy and fluid resuscitation—are critical determinants of survival. However, data describing the epidemiology, management delays, and outcomes of sepsis in Gaza are scarce. To determine the prevalence of sepsis among adult internal medicine admissions at a tertiary hospital in Gaza, Palestine, and to examine the association between early recognition, treatment delays, and key clinical outcomes, including mortality, ICU transfer, and length of hospital stay.A retrospective cohort study was conducted including all adult patients admitted to the Internal Medicine Department at tertiary hospital between 3 August 2025 and 31 December 2025. Sepsis was defined as suspected or confirmed infection with evidence of acute organ dysfunction documented in the medical record. Primary outcomes were in-hospital mortality and ICU transfer; length of hospital stay was a secondary outcome. Multivariable logistic and linear regression analyses were performed using SPSS version 27.During the study period, 3,699 adult patients were admitted to the Internal Medicine Department at tertiary hospital of these, 2,145 patients (58.0%) fulfilled the clinical criteria for sepsis based on documented infection and evidence of acute organ dysfunction. Figure 1 illustrates the patient flow and classification according to sepsis status.Septic patients were significantly older than non-septic patients (mean age 57.8 ± 14.2 years vs. 53.5 ± 12.1 years, p < 0.001). A higher proportion of septic patients had two or more chronic comorbidities (60.0% vs. 25.0%, p < 0.001). Sex distribution was comparable between the two groups, with no statistically significant difference observed (Table 1).When stratified by age group, mortality increased progressively with advancing age among septic patients: 21.4% in patients aged 18–39 years, 32.7% in those aged 40–59 years, and 48.9% in patients aged ≥60 years (p < 0.001). The median time from documented sepsis recognition to initiation of antibiotic therapy was 2.6 hours (IQR 1.4–4.8). Septic patients who received antibiotics within 1 hour of recognition had significantly lower in-hospital mortality compared with those treated after more than 3 hours (24.3% vs. 44.8%, p < 0.001). A stepwise increase in mortality was observed with increasing delays in antibiotic administration (Figure 2). Septic patients experienced substantially worse outcomes than non-septic patients. In-hospital mortality among septic patients was 37.5% compared with 15.8% in non-septic patients (p < 0.001). ICU transfer occurred in 50.0% of septic patients versus 14.0% of non-septic patients (p < 0.001). The mean length of hospital stay was significantly longer in the sepsis group (14.8 ± 5.2 days) compared with the non-sepsis group (8.1 ± 4.0 days; p < 0.001) (Table 2). Among septic patients, those requiring ICU transfer had markedly higher mortality than those managed exclusively on the medical ward (49.6% vs. 25.1%, p < 0.001), reflecting more advanced disease severity at presentation or delayed escalation of care. Multivariable logistic regression analysis identified increasing age (OR 1.04 per year, 95% CI 1.02–1.07), presence of ≥2 comorbidities (OR 3.80, 95% CI 2.40–6.10), delayed antibiotic administration (OR 1.30 per hour, 95% CI 1.15–1.48), and ICU transfer (OR 2.90, 95% CI 1.95–4.20) as independent predictors of in-hospital mortality (Table 3). Linear regression analysis demonstrated that ICU transfer (+6.0 days), presence of multiple comorbidities (+2.8 days), and delayed antibiotic initiation (+1.2 days per hour) were independently associated with prolonged hospitalization (Table 4).