Could qSOFA and SOFA score be correctly estimating the severity of healthcare-associated pneumonia?

Modified R-GLIM Score Is a Good Prognostic Tool to Predict a Long-Term Prognosis in Poor Conditioned Elderly Patients with Aspiration Pneumonia, a Pilot Study

BACKGROUND

While prognostic guidelines for pneumonia have widely allowed clinicians to treat patients, poor prognostic factors for 1- or 2-year survival times have never been mentioned to our knowledge.

PATIENTS AND METHODS

We conducted this retrospective study to evaluate whether malnutrition according to the GLIM criteria is a poor prognostic factor for 1- or 2-year survival among patients with aspiration pneumonia. All patients with community-onset aspiration pneumonia who were admitted to Aichi Medical University and had intervention from our nutrition support team (NST) in 2019 and 2020 were enrolled in this study.

RESULTS

A total of 56 patients were enrolled in the study. The mean age was 86 ± 6.5 and 25 (45%) were male. Thirty-one patients died during this observational period. Comparing the survival and death group, higher respiratory rate (RR) and malnutrition were seen more frequently in the death group than in the survival group. Then, the patients were divided into the following three groups: those with an RR ≥ 22 and malnutrition, those with malnutrition, and a control group [patients who were not malnourished and had a low RR (<22)]. Comparing the three groups, patients with an RR ≥ 22 and malnutrition had significantly shorter overall survival times (OSs) than those in the other groups (p = 0.009 by Log-Rank test) for 1-year prognosis. The result of 2-year prognosis displayed a statistical significance that was the same as that for 1-year prognosis (p = 0.004 by Log-Rank test). The Cox hazard regression model showed that a higher RR was an independent poor prognostic factor for 1- and 2-year survival among aspiration pneumonia patients.

CONCLUSIONS

This pilot study showed that combined scores of higher RR and malnutrition according to the GLIM criteria (modified R-GLIM score) was an independent poor prognostic factor for 1 or 2-year survival among super-elderly patients (aged over 80 years) with aspiration pneumonia.

Nrf2/PHB2 alleviates mitochondrial damage and protects against Staphylococcus aureus-induced acute lung injury

Staphylococcus aureus (SA) is a major cause of sepsis, leading to acute lung injury (ALI) characterized by inflammation and oxidative stress. However, the role of the Nrf2/PHB2 pathway in SA-induced ALI (SA-ALI) remains unclear. In this study, serum samples were collected from SA-sepsis patients, and a SA-ALI mouse model was established by grouping WT and Nrf2-/- mice after 6 h of intraperitoneal injection. A cell model simulating SA-ALI was developed using lipoteichoic acid (LTA) treatment. The results showed reduced serum Nrf2 levels in SA-sepsis patients, negatively correlated with the severity of ALI. In SA-ALI mice, downregulation of Nrf2 impaired mitochondrial function and exacerbated inflammation-induced ALI. Moreover, PHB2 translocation from mitochondria to the cytoplasm was observed in SA-ALI. The p-Nrf2/total-Nrf2 ratio increased in A549 cells with LTA concentration and treatment duration. Nrf2 overexpression in LTA-treated A549 cells elevated PHB2 content on the inner mitochondrial membrane, preserving genomic integrity, reducing oxidative stress, and inhibiting excessive mitochondrial division. Bioinformatic analysis and dual-luciferase reporter assay confirmed direct binding of Nrf2 to the PHB2 promoter, resulting in increased PHB2 expression. In conclusion, Nrf2 plays a role in alleviating SA-ALI by directly regulating PHB2 transcription and maintaining mitochondrial function in lung cells.

Evaluation of Systemic Antifungal Use in a Latin American General Care Hospital: A Retrospective Study

BACKGROUND

Invasive fungal infections significantly contribute to mortality and morbidity rates. Despite the presence of all four major classes of antifungal medications, it is estimated that these infections result in the death of 1.5 million people each year, and death rates are increasing at an alarming rate. With increasing concerns about the emergence of antifungal resistance, there is a growing consideration in many countries to incorporate antifungal stewardship into existing antimicrobial stewardship programs. This approach aims to address issues hindering the appropriate use of antifungal drugs and to optimize their utilization.

METHODS

An analytical retrospective study of 48 hospitalized patients was conducted to assess factors related to the use of systemic antifungals and develop and implement an internal protocol to improve its use.

RESULTS

All patients with severe comorbidity had SOFA scores linked with a mortality risk of more than 10%. Based on 48 evaluations of antifungal orders, 62.5% were considered appropriate, 14.6% were considered debatable, and 22.9% were considered inappropriate. Infectious disease physicians made most of the prescriptions considered appropriate in this study.

CONCLUSIONS

Comorbidities and risk factors in patients receiving systemic antifungals can be associated with the development of more serious fungal infections; hence, the implementation of antifungal stewardship as a complement to antimicrobial stewardship programs can help facilitate decision-making when dealing with a suspected case of fungal infection.

Ceftazidime/Avibactam, Polymyxin or Tigecycline as a Rescue Strategy for the Treatment of Carbapenem-Resistant Klebsiella pneumoniae in Bloodstream Infection: A Retrospective Cohort Study

Objective

To analyze the clinical characteristics, outcomes, and risk factors of patients treated with ceftazidime/avibactam, polymyxin, or tigecycline (CPT) compared with those receiving a conventional therapy (CT) (ie, imipenem, levofloxacin, or gentamicin).

Methods

A single-center retrospective cohort study included patients with carbapenem-resistant Klebsiella pneumoniae bloodstream infection (CRKP-BSI) treated at one Chinese tertiary hospital between March 2012 and November 2022 was performed. Clinical characteristics, outcomes, and risk factors of patients treated with CPT or CT were compared. Predictors of 30-day mortality of patients with CRKP-BSI were also analysed in our study.

Results

Among 184 recruited patients with CRKP-BSI, 39.7% (73/184) were treated with CPT, while 60.3% (111/184) were treated with CT. Compared to patients treated with CT, patients treated with CPT had worse conditions, as evidenced by a higher rate of underlying diseases and invasive procedures; however, they also had a better prognosis and lower rates of 14-day treatment failure (p = 0.024). In addition, univariate analysis and multivariate analysis showed that SOFA score [odds ratio (OR) = 1.310, 95% confidence interval (CI) 1.157-1.483; p < 0.001] and cold weather (OR = 3.658, 95% CI 1.474-9.081; p = 0.005) were independent risk factors for 30-day mortality.

Conclusion

Compared to CRKP-BSI patients treated with CT, patients treated with CPT had worse conditions but better prognoses. CRKP-BSI occurred more frequently in hot weather; however, higher 30-day mortality was associated with cold weather. A randomized trial is needed to confirm these observational results.

Combination of Sequential Organ Failure Assessment (SOFA) score and Charlson Comorbidity Index (CCI) could predict the severity and prognosis of candidemia more accurately than the Acute Physiology, Age, Chronic Health Evaluation II (APACHE II) score

BACKGROUND

Candidemia has emerged as an important nosocomial infection, with a mortality rate of 30-50%. It is the fourth most common nosocomial bloodstream infection (BSI) in the United States and the seventh most common nosocomial BSI in Europe and Japan. The aim of this study was to assess the performance of the Sequential Organ Failure Assessment (SOFA) score for determining the severity and prognosis of candidemia.

METHODS

We performed a retrospective study of patients admitted to hospital with candidemia between September 2014 and May 2018. The severity of candidemia was evaluated using the SOFA score and the Acute Physiology, Age, Chronic Health Evaluation II (APACHE II) score. Patients' underlying diseases were assessed by the Charlson Comorbidity Index (CCI).

RESULTS

Of 70 patients enrolled, 41 (59%) were males, and 29 (41%) were females. Their median age was 73 years (range: 36-93 years). The most common infection site was catheter-related bloodstream infection (n=36, 51%).The 30-day, and in-hospital mortality rates were 36 and 43%, respectively. Univariate analysis showed that SOFA score ≥5, APACHE II score ≥13, initial antifungal treatment with echinocandin, albumin < 2.3, C-reactive protein > 6, disturbance of consciousness, and CCI ≥3 were related with 30-day mortality. Of these 7, multivariate analysis showed that the combination of SOFA score ≥5 and CCI ≥3 was the best independent prognostic indicator for 30-day and in-hospital mortality.

CONCLUSIONS

The combined SOFA score and CCI was a better predictor of the 30-day mortality and in-hospital mortality than the APACHE II score alone.

Prognostic factors of 90-day mortality in older people with healthcare-associated pneumonia

AIM

The Quick Sequential Organ Failure Assessment, and confusion, urea, respiratory rate, blood pressure and age (CURB-65) scores have been used as prognostic factors of mortality related to healthcare-associated pneumonia. However, aspiration pneumonia remains unclear.

METHODS

A cross-sectional, prospective cohort study was carried out with 130 inpatients aged ≥75 years at a Geriatric ward of Kyorin University Hospital, Japan. We investigated the utility of aspiration pneumonia-related factors, latency of swallowing reflex and cough reflex sensitivity, serum albumin levels, the neutrophil-to- lymphocyte ratio, and conventional scores of pneumonia severity, for predicting 30- and 90-day healthcare-associated pneumonia mortality. Patient demographics, cognition, physical activity (Barthel Index), eating ability (Food Intake Level Scale), dementia stage (Functional Assessment Staging Tool), performance status (Zubrod score), current medications and comorbidities were collected. Pneumonia severity was evaluated using the Quick Sequential Organ Failure Assessment, CURB-65 and Systemic Inflammatory Response Syndrome criteria scores.

RESULTS

Age, Barthel Index, Zubrod, Functional Assessment Staging Tool and Food Intake Level Scale scores were significantly associated with mortality, whereas the conventional scores were not. The Kaplan-Meier method with the log-rank test using Cox proportional hazards analysis showed that serum albumin levels <2.75 and the comorbidity of atrial fibrillation were associated with a lower survival rate in deceased versus surviving individuals at 90 days. In addition, a deteriorated latency of swallowing reflex and a blunted cough reflex sensitivity were associated with 90-day mortality.

CONCLUSIONS

Hypoalbuminemia, atrial fibrillation, deteriorated latency of swallowing reflex and blunted cough reflex sensitivity values were better predictors of 90-day mortality than traditional scores in older individuals with healthcare-associated pneumonia. Geriatr Gerontol Int 2020; 20: 1036-1043..

Variation in SOFA (Sequential Organ Failure Assessment) Score Performance in Different Infectious States

INTRODUCTION

In this study, we investigated whether the Sequential Organ Failure Assessment (SOFA) score performance differs based on the type of infection among patients admitted to the intensive care unit (ICU) with infection.

MATERIALS AND METHODS

Single-center, retrospective study of adult ICU patients admitted with infection between January 2008 and April 2018 at an urban tertiary care center. Patients were uniquely classified into different infection types based on International Classification of Diseases, Ninth Revision (ICD-9) and ICD-10 codes. Infection types included were pneumonia, meningitis, bacteremia, cellulitis, cholangitis/cholecystitis, intestinal and diarrheal disease, endocarditis, urinary tract infection (UTI), and peritonitis. The SOFA score performance and mortality in relation to SOFA score were compared across infection types.

RESULTS

A total of 12 283 patients were included. Of these, 50.6% were female and the median age was 70 years (interquartile range: 57-82). The most common infection types were pneumonia (32.2%) and UTI (31.0%). Overall, 1703 (13.9%) patients died prior to hospital discharge. The median baseline SOFA score (within 24 hours of ICU admission) for the cohort was 5 (3-8). Patients with peritonitis had the highest median SOFA score, 7 (4-9), and patients with cellulitis and UTI had the lowest median SOFA score, 4 (2-7). The SOFA score discrimination to predict mortality was highest among patients with endocarditis (area under the receiver operating characteristic [AUC]: 0.79, 95% CI: 0.69-0.90) and lowest for patients with isolated bacteremia (AUC: 0.59, 95% CI: 0.49-0.70). Observed mortality by quartile of SOFA score differed substantially across infection types.

CONCLUSIONS

Type of infection is an important consideration when interpreting the SOFA score. This is relevant as SOFA emerges as an important tool in the definition and prognostication of sepsis.

Impact of high plasma concentrations of linezolid in Taiwanese adult patients- therapeutic drug monitoring in improving adverse drug reactions

BACKGROUND

Previous studies have shown that the development of thrombocytopenia was associated with the elevated plasma concentration of linezolid, but little is known about the relationship between other uncommon adverse drug reactions (ADRs) and plasma concentration. The appropriate dosing adjustment has remained controversial. This prospective observational study was conducted to investigate the association between the plasma concentration of linezolid, ADRs, and clinical outcomes.

METHODS

Adult patients on linezolid treatment undergoing at least one therapeutic drug monitoring (TDM) were enrolled. The association between linezolid concentrations and ADRs was examined by multivariate Cox regression model. Predictors of linezolid concentrations was determined by linear regression model. The cut-off point of linezolid concentration and the effect of dosing adjustments based on TDM was also explored.

RESULTS

Of 50 patients enrolled in the study, plasma concentrations were 1.5-3 times higher than what was described in the prescribing information. The median minimum concentration (C_min) was significantly higher in patients with thrombocytopenia compared to patients without thrombocytopenia (13.0 vs. 7.2 μg/mL, P = 0.0273), and a higher median maximum concentration was also observed in patients with lactic acidosis (33.0 vs. 27.5 μg/mL, P = 0.0420). The C_min was elevated in patients with advanced age and severely impaired renal function. Dosing adjustment tailored by early TDM with the upper limit of C_min 9 μg/mL may improve platelet counts.

CONCLUSION

Elevated linezolid concentrations were associated with thrombocytopenia and lactic acidosis. TDM-guided dosing adjustment could be considered as a pragmatic way to mitigate thrombocytopenia.

The SOFA score could predict the severity and prognosis of infective endocarditis

INTRODUCTION

Although infectious endocarditis (IE) is a potentially severe infectious disease, there are no prognostic tools for in-hospital mortality for IE patients. This is the first report documenting that the Sequential Organ Failure Assessment (SOFA) score could evaluate the severity and outcome among IE patients.

PATIENTS AND METHODS

From 2007 to 2018, we reviewed all patients who were diagnosed as having IE at our institue. Patients diagnosed as definite IE according to the modified Duke criteria or by surgical procedure were included in this study.

RESULTS

A total of 66 IE patients were enrolled in this study. They were 45 males (68%) and the median age was 70 years. As for prognostic factors for in-hospital death among IE patients, SOFA score ≥6, CCI ≥3, surgical procedure, heart failure, immunological phenomena and detection of S. aureus as a causative pathogen were identified as prognostic factors by univariate analysis. Of these 6 factors, SOFA score ≥6 (OR 7.6, 95%CI 1.3-46.6, p = 0.029), heart failure (OR 9.7, 95%CI 1.1-86.1, p = 0.042), surgery (OR 0.1, 95%CI 0-0.8, p = 0.037) and immunological phenomena (OR 0.1, 95%CI 0-0.9, p = 0.042) were independent prognostic factors for in-hospital mortality among IE by logistic regression analysis.

CONCLUSION

The SOFA score could be a good prognostic tool to use for IE patients. Also, SOFA score ≥6, surgery, immunological phenomena and heart failure were independent prognostic factors for in-hospital mortality among IE patients.

Healthcare-associated pneumonia: is there any reason to continue to utilize this label in 2019?

BACKGROUND

There is an ongoing controversy on the role of the healthcare-associated pneumonia (HCAP) label in the treatment of patients with pneumonia.

OBJECTIVE

To provide an update of the literature on patients meeting criteria for HCAP between 2014 and 2018.

SOURCES

The review is based on a systematic literature search using PubMed-Central full-text archive of biomedical and life sciences literature at the U.S. National Institutes of Health's National Library of Medicine (NIH/NLM).

CONTENT

Studies compared clinical characteristics of patients with HCAP and community-acquired pneumonia (CAP). HCAP patients were older and had a higher comorbidity. Mortality rates in HCAP varied from 5% to 33%, but seemed lower than those cited in the initial reports. Criteria behind the HCAP classification differed considerably within populations. Microbial patterns differed in that there was a higher incidence of methicillin-resistant Staphylococcus aureus (MRSA) and Pseudomonas aeruginosa, and, to a lesser extent, enterobacteriaceae. Definitions and rates of multidrug-resistant (MDR) pneumonia also varied considerably. Broad-spectrum guideline-concordant treatment did not reduce mortality in four observational studies. The HCAP criteria performed poorly as a predictive tool to identify MDR pneumonia or pathogens not covered by treatment for CAP. A new score (Drug Resistance in Pneumonia, DRIP) outperformed HCAP in the prediction of MDR pathogens. Comorbidity and functional status, but not different microbial patterns, seem to account for increased mortality.

IMPLICATIONS

HCAP should no longer be used to identify patients at risk of MDR pathogens. The use of validated predictive scores along with implementation of de-escalation strategies and careful individual assessment of comorbidity and functional status seem superior strategies for clinical management.

Utility of the Quick Sequential Organ Failure Assessment in Japanese patients with nursing- and healthcare-associated pneumonia

AIM

To clarify the utility of sepsis evaluation using the Quick Sequential Organ Failure Assessment (qSOFA) tool in addition to the Pneumonia Severity Index (PSI); age, dehydration, respiration, orientation and blood pressure (A-DROP) index; and immunodeficiency, respiration, orientation, age and dehydration (I-ROAD) scoring systems, and risk factor evaluation of potentially drug-resistant (PDR) pathogens are suggested in the 2017 guidelines for pneumonia of the Japanese Respiratory Society in nursing- and healthcare-associated pneumonia patients.

METHODS

We included 289 hospitalized nursing- and healthcare-associated pneumonia patients between April 2016 and March 2017, and investigated the ability of PSI, A-DROP, I-ROAD and qSOFA to predict pneumonia-related mortality. We also evaluated the associations among the risk factors for PDR pathogens, the detection ratio of PDR pathogens and pneumonia-related mortality.

RESULTS

The mortality rate of pneumonia during hospitalization was 6.9% (20/289). The area under the curve for pneumonia-related mortality predicted using PSI, A-DROP, I-ROAD and qSOFA was 0.697 (95% confidence interval [CI] 0.59-0.80), 0.63 (95% CI 0.51-0.76), 0.61 (95% CI 0.52-0.70) and 0.701 (95% CI 0.59-0.81), respectively. In addition, higher areas under the curve were observed for pneumonia-related mortality predicted according to a combination of PSI and hypoalbuminemia (<2.5 g/dL) (0.75, 95% CI 0.64-0.86), and qSOFA and hypoalbuminemia (0.74, 95% CI 0.62-0.86) than for PSI and qSOFA alone. No significant associations were observed among the risk factors for PDR pathogens, the detection ratios of PDR pathogens and pneumonia-related mortality.

CONCLUSIONS

qSOFA and the combination of qSOFA and hypoalbuminemia might be simple and useful evaluation tools for predicting pneumonia-related mortality in nursing- and healthcare-associated pneumonia patients. Geriatr Gerontol Int 2019; 19: 177-183.

Role of qSOFA in predicting mortality of pneumonia: A systematic review and meta-analysis

BACKGROUND

The concept of sepsis was redefined recently, and a new screening system termed the quick Sequential Organ Failure Assessment (qSOFA) was recommended for identifying infected patients at high risk for death. However, the predictive value of qSOFA for mortality in patients with pneumonia remains unclear. Thus, we performed a meta-analysis with the aim of determining the prognostic value of qSOFA in predicting mortality in patients with pneumonia.

METHODS

Embase, Google Scholar, and PubMed (up to March 2018) were searched for related articles. We constructed a 2 × 2 contingency table according to mortality and qSOFA scores (<2 and ≥2) in patients with pneumonia. Two investigators independently extracted data and assessed study eligibility. A bivariate meta-analysis model was used to determine the prognostic value of qSOFA in predicting mortality. I index and Q-test were used to assess heterogeneity.

RESULTS

Six studies with 17,868 patients were included. A qSOFA score ≥2 was related to a higher risk for death in patients with pneumonia, with a pooled risk ratio (RR) was 3.35 (95% CI, 2.24-5.01) using a random-effects model (I = 89.4%). The pooled sensitivity and specificity of a qSOFA score ≥2 to predict mortality in patients with pneumonia were 0.43 (95% CI, 0.33-0.53) and 0.86 (95% CI, 0.76-0.92), respectively. The diagnostic OR was 4 (95% CI, 3-6). The area under the summary receiver operator characteristic (SROC) curve was 0.67 (95% CI, 0.63-0.71). When we calculated the community-acquired pneumonia (CAP) subgroup, the pooled sensitivity and specificity were 0.36 (95% CI, 0.26-0.48) and 0.91 (95% CI, 0.84-0.95), respectively. The area under the SROC curve was 0.70 (95% CI, 0.66-0.74).

CONCLUSIONS

A qSOFA score ≥2 is strongly associated with mortality in patients with pneumonia, but the poor sensitivity of qSOFA may have limitations in the early identification of mortality in patients with pneumonia.

Accuracy of quick Sequential Organ Failure Assessment (qSOFA) score and systemic inflammatory response syndrome (SIRS) criteria for predicting mortality in hospitalized patients with suspected infection: a meta-analysis of observational studies

OBJECTIVE

To identify sensitivity, specificity and predictive accuracy of quick sequential organ failure assessment (qSOFA) score and systemic inflammatory response syndrome (SIRS) criteria to predict in-hospital mortality in hospitalized patients with suspected infection.

METHODS

This meta-analysis followed the Meta-analysis of Observational Studies in Epidemiology (MOOSE) group consensus statement for conducting and reporting the results of systematic review. PubMed and EMBASE were searched for the observational studies which reported predictive utility of qSOFA score for predicting mortality in patients with suspected or proven infection with the following search words: 'qSOFA', 'q-SOFA', 'quick-SOFA', 'Quick Sequential Organ Failure Assessment', 'quick SOFA'. Sensitivity, specificity, area under receiver operating characteristic (ROC) curves with 95% confidence interval (CI) of qSOFA and SIRS criteria for predicting in-hospital mortality was collected for each study and a 2 × 2 table was created for each study.

RESULTS

Data of 406 802 patients from 45 observational studies were included in this meta-analysis. Pooled sensitivity (95% CI) and specificity (95% CI) of qSOFA ≥2 for predicting mortality in patients who were not in an intensive care unit (ICU) was 0.48 (0.41-0.55) and 0.83 (0.78-0.87), respectively. Pooled sensitivity (95% CI) of qSOFA ≥2 for predicting mortality in patients (both ICU and non-ICU settings) with suspected infection was 0.56 (0.47-0.65) and pooled specificity (95% CI) was 0.78 (0.71-0.83).

CONCLUSION

qSOFA has been found to be a poorly sensitive predictive marker for in-hospital mortality in hospitalized patients with suspected infection. It is reasonable to recommend developing another scoring system with higher sensitivity to identify high-risk patients with infection.