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Nguyen PH, Fay KA, English JM, Gill HS. Serial measurements of SIRS and SEP scores to identify unique phenotypes of sepsis. Intern Emerg Med 2024; 19:1099-1107. [PMID: 38372887 DOI: 10.1007/s11739-023-03512-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2023] [Accepted: 12/12/2023] [Indexed: 02/20/2024]
Abstract
Using scoring systems in discreet microbiologic cohorts in a serial fashion to identify unique phenotypes of sepsis remains unknown. Single-center, retrospective study that screened adults who triggered the hospital's SIRS (systemic inflammatory response syndrome) based sepsis alert into culture positive (Cx +) and culture negative (Cx-) groups. Subgroups were based on the location where the SIRS alert fired. SIRS scores and a novel score called SEP were calculated at t = 0 and at 3, 6, 12, and 24 h before and after t = 0. Primary outcome was a difference in SIRS/SEP scores in Cx + or Cx- groups over time. Secondary outcomes were differences in total SIRS/SEP scores and the components constituting SIRS/SEP scores at various locations over time. The study contained 7955 patients who met inclusion criteria. Cx + and Cx- groups had increases in SIRS/SEP scores and at similar rates starting 6 hours before t = 0. Both culture groups had decreasing SIRS/SEP scores, at varying gradients compared to the change in SIRS/SEP scores seen prior to t = 0. This pattern in SIRS/SEP scores before and after t = 0 was consistent in all location subgroups. Statistically significant differences were seen in the overall SIRS/SEP scores for Cx + and Cx- groups at hours 6, 12, and 24 after t = 0, in the ED group at t = 24 h after t = 0, the floor group at t = 0 h, and in the step-down group at t = 3 h after t = 0 h. Microbiological cohorting and serial assessments may be an effective tool to identify homogenous phenotypes of sepsis.
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Affiliation(s)
- Phuong Hoang Nguyen
- Geisel School of Medicine at Dartmouth, 1 Rope Ferry Road, Hanover, NH, 03755, USA
| | - Kayla Ashley Fay
- Section of Thoracic Surgery, Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - Jada Mae English
- Geisel School of Medicine at Dartmouth, 1 Rope Ferry Road, Hanover, NH, 03755, USA
| | - Harman Singh Gill
- Geisel School of Medicine at Dartmouth, 1 Rope Ferry Road, Hanover, NH, 03755, USA.
- Department of Medicine, Section of Pulmonary & Critical Care Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA.
- Department of Emergency Medicine, Dartmouth-Hitchcock Medical Center, 1 Medical Center Drive, Lebanon, NH, 03756, USA.
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Advani SD, Ratz D, Horowitz JK, Petty LA, Fakih MG, Schmader K, Mody L, Czilok T, Malani AN, Flanders SA, Gandhi TN, Vaughn VM. Bacteremia From a Presumed Urinary Source in Hospitalized Adults With Asymptomatic Bacteriuria. JAMA Netw Open 2024; 7:e242283. [PMID: 38477915 PMCID: PMC10938177 DOI: 10.1001/jamanetworkopen.2024.2283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Accepted: 01/23/2024] [Indexed: 03/14/2024] Open
Abstract
Importance Guidelines recommend withholding antibiotics in asymptomatic bacteriuria (ASB), including among patients with altered mental status (AMS) and no systemic signs of infection. However, ASB treatment remains common. Objectives To determine prevalence and factors associated with bacteremia from a presumed urinary source in inpatients with ASB with or without AMS and estimate antibiotics avoided if a 2% risk of bacteremia were used as a threshold to prompt empiric antibiotic treatment of ASB. Design, Setting, and Participants This cohort study assessed patients hospitalized to nonintensive care with ASB (no immune compromise or concomitant infections) in 68 Michigan hospitals from July 1, 2017, to June 30, 2022. Data were analyzed from August 2022 to January 2023. Main Outcomes and Measures The primary outcome was prevalence of bacteremia from a presumed urinary source (ie, positive blood culture with matching organisms within 3 days of urine culture). To determine factors associated with bacteremia, we used multivariable logistic regression models. We estimated each patient's risk of bacteremia and determined what percentage of patients empirically treated with antibiotics had less than 2% estimated risk of bacteremia. Results Of 11 590 hospitalized patients with ASB (median [IQR] age, 78.2 [67.7-86.6] years; 8595 female patients [74.2%]; 2235 African American or Black patients [19.3%], 184 Hispanic patients [1.6%], and 8897 White patients [76.8%]), 8364 (72.2%) received antimicrobial treatment for UTI, and 161 (1.4%) had bacteremia from a presumed urinary source. Only 17 of 2126 patients with AMS but no systemic signs of infection (0.7%) developed bacteremia. On multivariable analysis, male sex (adjusted odds ratio [aOR], 1.45; 95% CI, 1.02-2.05), hypotension (aOR, 1.86; 95% CI, 1.18-2.93), 2 or more systemic inflammatory response criteria (aOR, 1.72; 95% CI, 1.21-2.46), urinary retention (aOR, 1.87; 95% CI, 1.18-2.96), fatigue (aOR, 1.53; 95% CI, 1.08-2.17), log of serum leukocytosis (aOR, 3.38; 95% CI, 2.48-4.61), and pyuria (aOR, 3.31; 95% CI, 2.10-5.21) were associated with bacteremia. No single factor was associated with more than 2% risk of bacteremia. If 2% or higher risk of bacteremia were used as a cutoff for empiric antibiotics, antibiotic exposure would have been avoided in 78.4% (6323 of 8064) of empirically treated patients with low risk of bacteremia. Conclusions and Relevance In patients with ASB, bacteremia from a presumed urinary source was rare, occurring in less than 1% of patients with AMS. A personalized, risk-based approach to empiric therapy could decrease unnecessary ASB treatment.
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Affiliation(s)
- Sonali D. Advani
- Division of Infectious Diseases, Duke University School of Medicine, Durham, North Carolina
| | - David Ratz
- Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan
| | | | - Lindsay A. Petty
- Division of Infectious Diseases, University of Michigan, Ann Arbor
| | | | - Kenneth Schmader
- Division of Geriatrics, Duke University School of Medicine, and Durham Veterans Affairs Healthcare System, Durham, North Carolina
| | - Lona Mody
- Division of Geriatrics, University of Michigan, Ann Arbor
| | - Tawny Czilok
- Division of Hospital Medicine, University of Michigan, Ann Arbor
| | | | | | - Tejal N. Gandhi
- Division of Infectious Diseases, University of Michigan, Ann Arbor
| | - Valerie M. Vaughn
- Division of Hospital Medicine, University of Michigan, Ann Arbor
- Division of General Internal Medicine, University of Utah School of Medicine, Salt Lake City
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Rincon TA, Raffa J, Celi LA, Badawi O, Johnson AEW, Pollard T, Deliberato RO, Pierce JD. Evaluation of evolving sepsis screening criteria in discriminating suspected sepsis and mortality among adult patients admitted to the intensive care unit. Int J Nurs Stud 2023; 145:104529. [PMID: 37307638 DOI: 10.1016/j.ijnurstu.2023.104529] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Revised: 04/08/2023] [Accepted: 05/14/2023] [Indexed: 06/14/2023]
Abstract
BACKGROUND Institutions struggle with successful use of sepsis alerts within electronic health records. OBJECTIVE Test the association of sepsis screening measurement criteria in discrimination of mortality and detection of sepsis in a large dataset. DESIGN Retrospective, cohort study using a large United States (U.S.) intensive care database. The Institutional Review Board exempt status was obtained from Kansas University Medical Center Human Research Protection Program (10-1-2015). SETTING 334 U.S. hospitals participating in the eICU Research Institute. PARTICIPANTS Nine hundred twelve thousand five hundred and nine adult intensive care admissions from 183 hospitals. METHODS Exposures included: systemic inflammatory response syndrome criteria ≥ 2 (Sepsis-1); systemic inflammatory response syndrome criteria with organ failure criteria ≥ 3.5 points (Sepsis-2); and sepsis-related organ failure assessment score ≥ 2 and quick score ≥ 2 (Sepsis-3). Discrimination of outcomes was determined with/without (adjusted/unadjusted) baseline risk exposure to a model. The receiver operating characteristic curve (AUROC) and odds ratios (ORs) for each decile of baseline risk of sepsis or death were assessed. RESULTS Within the eligible cohort of 912,509, a total of 86,219 (9.4 %) patients did not survive their hospital stay and 186,870 (20.5 %) met the definition of suspected sepsis. For suspected sepsis discrimination, Sepsis-2 (unadjusted AUROC 0.67, 99 % CI: 0.66-0.67 and adjusted AUROC 0.77, 99 % CI: 0.77-0.77) outperformed Sepsis-3 (SOFA unadjusted AUROC 0.61, 99 % CI: 0.61-0.61 and adjusted AUROC 0.74, 99 % CI: 0.74-0.74) (qSOFA unadjusted AUROC 0.59, 99 % CI: 0.59-0.60 and adjusted AUROC 0.73, 99 % CI: 0.73-0.73). Sepsis-2 also outperformed Sepsis-1 (unadjusted AUROC 0.58, 99 % CI: 0.58-0.58 and adjusted AUROC 0.73, 99 % CI: 0.73-0.73). In between differences of AUROCs were statistically significantly different. Sepsis-2 ORs were higher for the outcome of suspected sepsis when considering deciles of risk than the other measurement systems. CONCLUSIONS AND RELEVANCE Sepsis-2 outperformed other systems in suspected sepsis detection and was comparable to SOFA in prognostic accuracy of mortality in adult intensive care patients.
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Affiliation(s)
- Teresa A Rincon
- UMass Chan Medical School, Tan Chingfen Graduate School of Nursing, 55 Lake Ave, North Worcester, MA 01655, USA; Blue Cirrus Consulting, 8595 Pelham Rd #400-402, Greenville, SC 29615, USA.
| | - Jesse Raffa
- Laboratory for Computational Physiology, Institute of Medical Engineering & Science, Massachusetts Institute of Technology, Cambridge, MA 02139, USA
| | - Leo Anthony Celi
- Laboratory for Computational Physiology, Institute of Medical Engineering & Science, Massachusetts Institute of Technology, Cambridge, MA 02139, USA; Division of Pulmonary, Critical Care and Sleep Medicine, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA 02215, USA
| | - Omar Badawi
- Laboratory for Computational Physiology, Institute of Medical Engineering & Science, Massachusetts Institute of Technology, Cambridge, MA 02139, USA; Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, Baltimore, MD 21201, USA
| | - Alistair E W Johnson
- Child Health Evaluative Sciences, Peter Gilgan Centre for Research & Learning, The Hospital for Sick Children, 686 Bay St., Toronto, ON M5G 0A4, Canada
| | - Tom Pollard
- Laboratory for Computational Physiology, Institute of Medical Engineering & Science, Massachusetts Institute of Technology, Cambridge, MA 02139, USA
| | - Rodrigo Octávio Deliberato
- Laboratory for Computational Physiology, Institute of Medical Engineering & Science, Massachusetts Institute of Technology, Cambridge, MA 02139, USA
| | - Janet D Pierce
- University of Kansas, School of Nursing, Kansas City, KS 66160, USA
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Niggli C, Vetter P, Hambrecht J, Niggli P, Vomela J, Chaloupka R, Pape HC, Mica L. IBM WATSON Trauma Pathway Explorer© as a Predictor for Sepsis after Polytrauma - Is Procalcitonin Useful for Identifying Septic Polytrauma Patients? JOURNAL OF SURGERY AND RESEARCH 2022; 5:637-644. [PMID: 36816532 PMCID: PMC9937584 DOI: 10.26502/jsr.10020272] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/18/2023]
Abstract
IBM and the University Hospital Zurich have developed an online tool for predicting outcomes of a patient with polytrauma, the IBM WATSON Trauma Pathway Explorer® . The three predicted outcomes are Systemic Inflammatory Response Syndrome (SIRS) and sepsis within 21 days as well as early death within 72 hours since the admission of the patient. The validated Trauma Pathway Explorer® offers insights into the most common laboratory parameters, such as procalcitonin (PCT). Sepsis is one of the most important complications after polytrauma, which is why it is crucial to detect it early. This study aimed to examine the time-dependent relationship between PCT values and sepsis, based on the WATSON technology. A total of 3653 patients were included, and ongoing admissions are incorporated continuously. Patients were split into two groups (sepsis and non-sepsis), and the PCT value was assessed for 21 days (1, 2, 3, 4, 6, 8, 12, 24, 48 hours, and 3, 4, 5, 7, 10, 14 and 21 days). The Mann-Whitney U-Test was used to evaluate the difference between the two groups. Binary logistic regression was utilized to examine the dependency of prediction. The Closest Top-left Threshold Method provided time-specific thresholds at which the PCT level is predictive for sepsis. At p <0.05, the data were declared significant. R was used to conduct all statistical analyses. The Mann-Whitney U-test showed a significant difference in PCT values in sepsis and non-sepsis patients between 12 and 24 hours, including post-hoc analysis (p <0.05). Likewise, the p-value started to be significant between 12 and 24 hours in the binary logistic regression (p <0.05). The threshold value of PCT to predict sepsis at 24 hours is 0.7μg/l, and at 48 hours 0.5μg/l. The presented time course of PCT levels in polytrauma patients shows the PCT as a separate predictor for sepsis relatively early. Even later, during the 21-day observation period, time-dependent PCT values may be utilized as a benchmark for the early and preemptive detection of sepsis, which may reduce death from septic shock and other deadly infectious episodes.
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Affiliation(s)
- Cédric Niggli
- Department of Trauma Surgery, University Hospital Zurich, 8091 Zurich, Switzerland
| | - Philipp Vetter
- Department of Trauma Surgery, University Hospital Zurich, 8091 Zurich, Switzerland
| | - Jan Hambrecht
- Department of Trauma Surgery, University Hospital Zurich, 8091 Zurich, Switzerland
| | - Philipp Niggli
- Department of Mathematics, ETH Zurich, 8092 Zurich, Switzerland
| | - Jindřich Vomela
- Division of Medical Sciences in Sportsmedicine, Faculty of Sports Studies, Masaryks University, 62500 Brno, Czech Republic
| | - Richard Chaloupka
- Department of Orthopedic Surgery, Masaryks University, 62500 Brno, Czech Republic
| | - Hans-Christoph Pape
- Department of Trauma Surgery, University Hospital Zurich, 8091 Zurich, Switzerland
| | - Ladislav Mica
- Department of Trauma Surgery, University Hospital Zurich, 8091 Zurich, Switzerland
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Schena CA, de’Angelis GL, Carra MC, Bianchi G, de’Angelis N. Antimicrobial Challenge in Acute Care Surgery. Antibiotics (Basel) 2022; 11:antibiotics11101315. [PMID: 36289973 PMCID: PMC9598495 DOI: 10.3390/antibiotics11101315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Revised: 09/24/2022] [Accepted: 09/26/2022] [Indexed: 12/07/2022] Open
Abstract
The burden of infections in acute care surgery (ACS) is huge. Surgical emergencies alone account for three million admissions per year in the United States (US) with estimated financial costs of USD 28 billion per year. Acute care facilities and ACS patients represent boost sanctuaries for the emergence, development and transmission of infections and multi-resistant organisms. According to the World Health Organization, healthcare-associated infections affected around 4 million cases in Europe and 1.7 million in the US alone in 2011 with 39,000 and 99,000 directly attributable deaths, respectively. In this scenario, antimicrobial resistance arose as a public-health emergency that worsens patients’ morbidity and mortality and increases healthcare costs. The optimal patient care requires the application of comprehensive evidence-based policies and strategies aiming at minimizing the impact of healthcare associated infections and antimicrobial resistance, while optimizing the treatment of intra-abdominal infections. The present review provides a snapshot of two hot topics, such as antimicrobial resistance and systemic inflammatory response, and three milestones of infection management, such as source control, infection prevention, and control and antimicrobial stewardship.
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Affiliation(s)
- Carlo Alberto Schena
- Unit of Digestive and HPB Surgery, CARE Department, Henri Mondor Hospital, AP-HP, 94010 Créteil, France
| | - Gian Luigi de’Angelis
- Gastroenterology and Endoscopy Unit, Department of Medicine and Surgery, University Hospital of Parma, 43126 Parma, Italy
- Correspondence:
| | - Maria Clotilde Carra
- Rothschild Hospital, AP-HP, Université Paris Cité, U.F.R. of Odontology, 75006 Paris, France
| | - Giorgio Bianchi
- Unit of Digestive and HPB Surgery, CARE Department, Henri Mondor Hospital, AP-HP, 94010 Créteil, France
| | - Nicola de’Angelis
- Unit of Digestive and HPB Surgery, CARE Department, Henri Mondor Hospital, AP-HP, 94010 Créteil, France
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Prescott HC, Seelye S, Wang XQ, Hogan CK, Smith JT, Kipnis P, Barreda F, Donnelly JP, Pogue JM, Iwashyna TJ, Jones MM, Liu VX. Temporal Trends in Antimicrobial Prescribing During Hospitalization for Potential Infection and Sepsis. JAMA Intern Med 2022; 182:805-813. [PMID: 35759274 PMCID: PMC9237797 DOI: 10.1001/jamainternmed.2022.2291] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Accepted: 04/28/2022] [Indexed: 12/19/2022]
Abstract
Importance Some experts have cautioned that national and health system emphasis on rapid administration of antimicrobials for sepsis may increase overall antimicrobial use even among patients without sepsis. Objective To assess whether temporal changes in antimicrobial timing for sepsis are associated with increasing antimicrobial use, days of therapy, or broadness of antimicrobial coverage among all hospitalized patients at risk for sepsis. Design, Setting, and Participants This is an observational cohort study of hospitalized patients at 152 hospitals in 2 health care systems during 2013 to 2018, admitted via the emergency department with 2 or more systemic inflammatory response syndrome (SIRS) criteria. Data analysis was performed from June 10, 2021, to March 22, 2022. Exposures Hospital-level temporal trends in time to first antimicrobial administration. Outcomes Antimicrobial outcomes included antimicrobial use, days of therapy, and broadness of antibacterial coverage. Clinical outcomes included in-hospital mortality, 30-day mortality, length of hospitalization, and new multidrug-resistant (MDR) organism culture positivity. Results Among 1 559 523 patients admitted to the hospital via the emergency department with 2 or more SIRS criteria (1 269 998 male patients [81.4%]; median [IQR] age, 67 [59-77] years), 273 255 (17.5%) met objective criteria for sepsis. In multivariable models adjusted for patient characteristics, the adjusted median (IQR) time to first antimicrobial administration to patients with sepsis decreased by 37 minutes, from 4.7 (4.1-5.3) hours in 2013 to 3.9 (3.6-4.4) hours in 2018, although the slope of decrease varied across hospitals. During the same period, antimicrobial use within 48 hours, days of antimicrobial therapy, and receipt of broad-spectrum coverage decreased among the broader cohort of patients with SIRS. In-hospital mortality, 30-day mortality, length of hospitalization, new MDR culture positivity, and new MDR blood culture positivity decreased over the study period among both patients with sepsis and those with SIRS. When examining hospital-specific trends, decreases in antimicrobial use, days of therapy, and broadness of antibacterial coverage for patients with SIRS did not differ by hospital antimicrobial timing trend for sepsis. Overall, there was no evidence that accelerating antimicrobial timing for sepsis was associated with increasing antimicrobial use or impaired antimicrobial stewardship. Conclusions and Relevance In this multihospital cohort study, the time to first antimicrobial for sepsis decreased over time, but this trend was not associated with increasing antimicrobial use, days of therapy, or broadness of antimicrobial coverage among the broader population at-risk for sepsis, which suggests that shortening the time to antibiotics for sepsis is feasible without leading to indiscriminate antimicrobial use.
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Affiliation(s)
- Hallie C. Prescott
- Department of Internal Medicine, University of Michigan, Ann Arbor
- VA Center for Clinical Management Research, Ann Arbor, Michigan
| | - Sarah Seelye
- VA Center for Clinical Management Research, Ann Arbor, Michigan
| | - Xiao Qing Wang
- Department of Internal Medicine, University of Michigan, Ann Arbor
| | | | - Joshua T. Smith
- Division of Research, Kaiser Permanente Northern California, Oakland
| | - Patricia Kipnis
- Division of Research, Kaiser Permanente Northern California, Oakland
| | - Fernando Barreda
- Division of Research, Kaiser Permanente Northern California, Oakland
| | - John P. Donnelly
- Department of Learning Health Sciences, University of Michigan, Ann Arbor
| | - Jason M. Pogue
- Department of Clinical Pharmacy, University of Michigan College of Pharmacy, Ann Arbor
| | - Theodore J. Iwashyna
- Department of Internal Medicine, University of Michigan, Ann Arbor
- VA Center for Clinical Management Research, Ann Arbor, Michigan
| | - Makoto M. Jones
- Salt Lake City VA Healthcare System, Salt Lake City, Utah
- Department of Medicine, University of Utah, Salt Lake City
| | - Vincent X. Liu
- Division of Research, Kaiser Permanente Northern California, Oakland
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7
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Dutta S, McEvoy DS, Rubins DM, Dighe AS, Filbin MR, Rhee C. Clinical decision support improves blood culture collection before intravenous antibiotic administration in the emergency department. J Am Med Inform Assoc 2022; 29:1705-1714. [PMID: 35877074 PMCID: PMC9471721 DOI: 10.1093/jamia/ocac115] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Revised: 06/07/2022] [Accepted: 07/21/2022] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE Surviving Sepsis guidelines recommend blood cultures before administration of intravenous (IV) antibiotics for patients with sepsis or moderate to high risk of bacteremia. Clinical decision support (CDS) that reminds emergency department (ED) providers to obtain blood cultures when ordering IV antibiotics may lead to improvements in this process measure. METHODS This was a multicenter causal impact analysis comparing timely blood culture collections prior to IV antibiotics for adult ED patients 1 year before and after a CDS intervention implementation in the electronic health record. A Bayesian structured time-series model compared daily timely blood cultures collected compared to a forecasted synthetic control. Mixed effects models evaluated the impact of the intervention controlling for confounders. RESULTS The analysis included 54 538 patients over 2 years. In the baseline phase, 46.1% had blood cultures prior to IV antibiotics, compared to 58.8% after the intervention. Causal impact analysis determined an absolute increase of 13.1% (95% CI 10.4-15.7%) of timely blood culture collections overall, although the difference in patients with a sepsis diagnosis or who met CDC Adult Sepsis Event criteria was not significant, absolute difference 8.0% (95% CI -0.2 to 15.8). Blood culture positivity increased in the intervention phase, and contamination rates were similar in both study phases. DISCUSSION CDS improved blood culture collection before IV antibiotics in the ED, without increasing overutilization. CONCLUSION A simple CDS alert increased timely blood culture collections in ED patients for whom concern for infection was high enough to warrant IV antibiotics.
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Affiliation(s)
- Sayon Dutta
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA.,Mass General Brigham Digital Health, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Dustin S McEvoy
- Mass General Brigham Digital Health, Boston, Massachusetts, USA
| | - David M Rubins
- Mass General Brigham Digital Health, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA.,Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Anand S Dighe
- Mass General Brigham Digital Health, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA.,Department of Pathology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Michael R Filbin
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Chanu Rhee
- Division of Infectious Diseases, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Department of Population Medicine, Harvard Medical School/Harvard Pilgrim Health Care Institute, Boston, Massachusetts, USA
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Mollura M, Lehman LWH, Mark RG, Barbieri R. A novel artificial intelligence based intensive care unit monitoring system: using physiological waveforms to identify sepsis. PHILOSOPHICAL TRANSACTIONS. SERIES A, MATHEMATICAL, PHYSICAL, AND ENGINEERING SCIENCES 2021; 379:20200252. [PMID: 34689614 PMCID: PMC8805602 DOI: 10.1098/rsta.2020.0252] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 04/16/2021] [Indexed: 05/02/2023]
Abstract
A massive amount of multimodal data are continuously collected in the intensive care unit (ICU) along each patient stay, offering a great opportunity for the development of smart monitoring devices based on artificial intelligence (AI). The two main sources of relevant information collected in the ICU are the electronic health records (EHRs) and vital sign waveforms continuously recorded at the bedside. While EHRs are already widely processed by AI algorithms for prompt diagnosis and prognosis, AI-based assessments of the patients' pathophysiological state using waveforms are less developed, and their use is still limited to real-time monitoring for basic visual vital sign feedback at the bedside. This study uses data from the MIMIC-III database (PhysioNet) to propose a novel AI approach in ICU patient monitoring that incorporates features estimated by a closed-loop cardiovascular model, with the specific goal of identifying sepsis within the first hour of admission. Our top benchmark results (AUROC = 0.92, AUPRC = 0.90) suggest that features derived by cardiovascular control models may play a key role in identifying sepsis, by continuous monitoring performed through advanced multivariate modelling of vital sign waveforms. This work lays foundations for a deeper data integration paradigm which will help clinicians in their decision-making processes. This article is part of the theme issue 'Advanced computation in cardiovascular physiology: new challenges and opportunities'.
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Affiliation(s)
- Maximiliano Mollura
- Department of Electronics, Information and Bioengineering, Politecnico di Milano, Milano, Italy
| | - Li-Wei H. Lehman
- Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Roger G. Mark
- Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Riccardo Barbieri
- Department of Electronics, Information and Bioengineering, Politecnico di Milano, Milano, Italy
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9
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Nkonge E, Kituuka O, Ocen W, Ariaka H, Ogwal A, Ssekitoleko B. Comparison of QSOFA and sirs scores for the prediction of adverse outcomes of secondary peritonitis among patients admitted on the adult surgical ward in a tertiary teaching hospital in Uganda: a prospective cohort study. BMC Emerg Med 2021; 21:128. [PMID: 34742255 PMCID: PMC8571823 DOI: 10.1186/s12873-021-00528-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Accepted: 10/24/2021] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND SIRS and qSOFA are two ancillary scoring tools that have been used globally, inside and outside of ICU to predict adverse outcomes of infections such as secondary peritonitis. A tertiary teaching hospital in Uganda uses SIRS outside the ICU to identify patients with secondary peritonitis, who are at risk of adverse outcomes. However, there are associated delays in decision making given SIRS partial reliance on laboratory parameters which are often not quickly available in a resource limited emergency setting. In response to the practical limitations of SIRS, the sepsis-3 task force recommends qSOFA as a better tool. However, its performance in patients with secondary peritonitis in comparison to that of SIRS has not been evaluated in a resource limited setting of a tertiary teaching hospital in a low and middle income country like Uganda. OBJECTIVE To compare the performance of qSOFA and SIRS scores in predicting adverse outcomes of secondary peritonitis among patients on the adult surgical wards in a tertiary teaching hospital in Uganda. METHODS This was a prospective cohort study of patients with clinically confirmed secondary peritonitis, from March 2018 to January 2019 at the Accident and Emergency unit and the adult surgical wards of a tertiary teaching hospital in Uganda. QSOFA and SIRS scores were generated for each patient, with a score of ≥2 recorded as high risk, while a score of < 2 recorded as low risk for the adverse outcome respectively. After surgery, patients were followed up until discharge or death. In-hospital mortality and prolonged hospital stay were the primary and secondary adverse outcomes, respectively. Sensitivity, specificity, PPV, NPV and accuracy at 95% confidence interval were calculated for each of the scores using STATA v.13. RESULTS A total of 153 patients were enrolled. Of these, 151(M: F, 2.4:1) completed follow up and were analysed, 2 were excluded. Mortality rate was 11.9%. Fourty (26.5%) patients had a prolonged hospital stay. QSOFA predicted in-hospital mortality with AUROC of 0.52 versus 0.62, for SIRS. Similarly, qSOFA predicted prolonged hospital stay with AUROC of 0.54 versus 0.57, for SIRS. CONCLUSION SIRS is superior to qSOFA in predicting both mortality and prolonged hospital stay among patients with secondary peritonitis. However, overall, both scores showed a poor discrimination for both adverse outcomes and therefore not ideal tools.
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Affiliation(s)
- Emmanuel Nkonge
- Department of Surgery, Villa Maria Hospital, P.O Box 32, Masaka, Uganda
| | - Olivia Kituuka
- Department of Surgery, Makerere University, College of Health Sciences, P. O. Box 7072, Kampala, Uganda.
| | - William Ocen
- Department of Surgery, Lira University, P.O. Box 1035, Lira, Uganda
| | - Herbert Ariaka
- Department of Surgery, Uganda Heart Institute, Kampala, Uganda
| | - Alfred Ogwal
- Department of Surgery, Maridi County Hospital, Maridi, Western Equatoria State, South Sudan
| | - Badru Ssekitoleko
- Department of Surgery, Makerere University, College of Health Sciences, P. O. Box 7072, Kampala, Uganda
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10
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Simkins TJ, Bissig D, Moreno G, Kahlon NPK, Gorin F, Duffy A. A clinical decision rule predicting outcomes of emergency department patients with altered mental status. J Am Coll Emerg Physicians Open 2021; 2:e12522. [PMID: 34528023 PMCID: PMC8432088 DOI: 10.1002/emp2.12522] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Revised: 03/07/2021] [Accepted: 07/07/2021] [Indexed: 12/19/2022] Open
Abstract
STUDY OBJECTIVE Approximately 5% of emergency department patients present with altered mental status (AMS). AMS is diagnostically challenging because of the wide range of causes and is associated with high mortality. We sought to develop a clinical decision rule predicting admission risk among emergency department (ED) patients with AMS. METHODS Using retrospective chart review of ED encounters for AMS over a 2-month period, we recorded causes of AMS and numerous clinical variables. Encounters were split into those admitted to the hospital ("cases") and those discharged from the ED ("controls"). Using the first month's data, variables correlated with hospital admission were identified and narrowed using univariate and multivariate statistics, including recursive partitioning. These variables were then organized into a clinical decision rule and validated on the second month's data. The decision rule results were also compared to 1-year mortality. RESULTS We identified 351 encounters for AMS over a 2-month period. Significant contributors to AMS included intoxication and chronic disorder decompensation. ED data predicting hospital admission included vital sign abnormalities, select lab studies, and psychiatric/intoxicant history. The decision rule sorted patients into low, moderate, or high risk of admission (11.1%, 44.3%, and 89.1% admitted, respectively) and was predictive of 1-year mortality (low-risk group 1.8%, high-risk group 34.3%). CONCLUSIONS We catalogued common causes for AMS among patients presenting to the ED, and our data-driven decision tool triaged these patients for risk of admission with good predictive accuracy. These methods for creating clinical decision rules might be further studied and improved to optimize ED patient care.
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Affiliation(s)
- Tyrell J Simkins
- Department of NeurologyUniversity of California, DavisSacramentoCaliforniaUSA
| | - David Bissig
- Department of NeurologyUniversity of California, DavisSacramentoCaliforniaUSA
| | - Gabriel Moreno
- Department of NeurologyUniversity of California, DavisSacramentoCaliforniaUSA
- Touro UniversityVallejoCaliforniaUSA
| | - Nimar Pal K Kahlon
- Department of NeurologyUniversity of California, DavisSacramentoCaliforniaUSA
| | - Fredric Gorin
- Department of NeurologyUniversity of California, DavisSacramentoCaliforniaUSA
| | - Alexandra Duffy
- Department of NeurologyUniversity of California, DavisSacramentoCaliforniaUSA
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11
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Yeşil O, Pekdemir M, Özturan İU, Doğan NÖ, Yaka E, Yılmaz S, Karadaş A, Pınar SG. Performance of qSOFA, SIRS, and the qSOFA + SIRS combinations for predicting 30-day adverse outcomes in patients with suspected infection. Med Klin Intensivmed Notfmed 2021; 117:623-629. [PMID: 34586431 DOI: 10.1007/s00063-021-00870-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2021] [Revised: 08/04/2021] [Accepted: 08/20/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND The use of the quick sequential organ failure assessment score (qSOFA) score and systemic inflammatory response syndrome (SIRS) criteria to identify patients at high risk for adverse outcomes in the emergency department (ED) remains controversial due to their low predictive performance and lack of supporting evidence. This study aimed to determine the predictive performance of qSOFA, SIRS, and the qSOFA + SIRS combinations for adverse outcomes. METHODS All adult patients admitted to the ED with suspected infection were prospectively included. qSOFA scores ≥ 2, SIRS score ≥ 2 were defined as risk-positive for adverse outcome. Furthermore, combination‑1, which was defined as either qSOFA or SIRS positivity, and combination‑2, which was defined as both qSOFA and SIRS positivity, were also considered as risk-positive for adverse outcome. The predictive performance of qSOFA, SIRS, combination‑1, and combination‑2 for a composite adverse outcome within 30 days, including mortality, intensive care unit (ICU) admission, and non-ICU hospitalization, were determined. RESULTS A total of 350 patients were included in the analysis. The composite outcome occurred in 211 (60.3%) patients within 30 days: mortality in 84 (24%), ICU admission in 78 (22.3%), and non-ICU hospitalization in 154 (44%). The sensitivity and specificity, respectively, were determined in predicting composite outcome as 0.34 and 0.93 for qSOFA, 0.81 and 0.31 for SIRS, 0.84 and 0.28 for combination‑1, and 0.31 and 0.96 for combination‑2. CONCLUSION The study results suggest that qSOFA and combination‑2 could be a useful tool for confirming patients at high risk for adverse outcomes. Although SIRS and combination‑1 could be helpful for excluding high-risk patients, the requirement of white blood cell counts limits their utilization for screening.
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Affiliation(s)
- Olcay Yeşil
- Faculty of Medicine, Dept. of Emergency Medicine, Kocaeli University, Kabaoğlu, Baki Komsuoğlu bulvarı No:515, Umuttepe, 41001, İzmit, Kocaeli, Turkey
| | - Murat Pekdemir
- Faculty of Medicine, Dept. of Emergency Medicine, Kocaeli University, Kabaoğlu, Baki Komsuoğlu bulvarı No:515, Umuttepe, 41001, İzmit, Kocaeli, Turkey
| | - İbrahim Ulaş Özturan
- Faculty of Medicine, Dept. of Emergency Medicine, Kocaeli University, Kabaoğlu, Baki Komsuoğlu bulvarı No:515, Umuttepe, 41001, İzmit, Kocaeli, Turkey.
| | - Nurettin Özgür Doğan
- Faculty of Medicine, Dept. of Emergency Medicine, Kocaeli University, Kabaoğlu, Baki Komsuoğlu bulvarı No:515, Umuttepe, 41001, İzmit, Kocaeli, Turkey
| | - Elif Yaka
- Faculty of Medicine, Dept. of Emergency Medicine, Kocaeli University, Kabaoğlu, Baki Komsuoğlu bulvarı No:515, Umuttepe, 41001, İzmit, Kocaeli, Turkey
| | - Serkan Yılmaz
- Faculty of Medicine, Dept. of Emergency Medicine, Kocaeli University, Kabaoğlu, Baki Komsuoğlu bulvarı No:515, Umuttepe, 41001, İzmit, Kocaeli, Turkey
| | - Adnan Karadaş
- Faculty of Medicine, Dept. of Emergency Medicine, Kocaeli University, Kabaoğlu, Baki Komsuoğlu bulvarı No:515, Umuttepe, 41001, İzmit, Kocaeli, Turkey
| | - Seda Güney Pınar
- Faculty of Medicine, Dept. of Emergency Medicine, Kocaeli University, Kabaoğlu, Baki Komsuoğlu bulvarı No:515, Umuttepe, 41001, İzmit, Kocaeli, Turkey
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12
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Silva LMFD, Diogo LP, Vieira LB, Michielin FDC, Santarem MD, Machado MLP. Performance of scores in the prediction of clinical outcomes in patients admitted from the emergency service. Rev Lat Am Enfermagem 2021; 29:e3479. [PMID: 34495190 PMCID: PMC8432508 DOI: 10.1590/1518-8345.4722.3479] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Accepted: 04/17/2021] [Indexed: 11/24/2022] Open
Abstract
Objective: to evaluate the performance of the quickSOFA scores and Systemic Inflammatory Response Syndrome as predictors of clinical outcomes in patients admitted to an emergency service. Method: a retrospective cohort study, involving adult clinical patients admitted to the emergency service. Analysis of the ROC curve was performed to assess the prognostic indexes between scores and outcomes of interest. Multivariate analysis used Poisson regression with robust variance, evaluating the relationship between variables with biological plausibility and outcomes. Results: 122 patients were selected, 58.2% developed sepsis. Of these, 44.3% had quickSOFA ≥2 points, 87% developed sepsis, 55.6% septic shock and 38.9% died. In the evaluation of Systemic Inflammatory Response Syndrome, 78.5% obtained results >2 points; of these, 66.3% developed sepsis, 40% septic shock and 29.5% died. quickSOFA ≥2 showed greater specificity for diagnosis of sepsis in 86% of the cases, for septic shock 70% and for mortality 64%, whereas the second score showed better results for sensitivity with diagnosis of sepsis in 87.5%, septic shock in 92.7% and death in 90.3%. Conclusion: quickSOFA showed by its practicality that it can be used clinically within the emergency services, bringing clinical applicability from the risk classification of patients for the early recognition of unfavorable outcomes.
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Abstract
OBJECTIVES Assess the impact of heterogeneity among established sepsis criteria (Sepsis-1, Sepsis-3, Centers for Disease Control and Prevention Adult Sepsis Event, and Centers for Medicare and Medicaid severe sepsis core measure 1) through the comparison of corresponding sepsis cohorts. DESIGN Retrospective analysis of data extracted from electronic health record. SETTING Single, tertiary-care center in St. Louis, MO. PATIENTS Adult, nonsurgical inpatients admitted between January 1, 2012, and January 6, 2018. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS In the electronic health record data, 286,759 encounters met inclusion criteria across the study period. Application of established sepsis criteria yielded cohorts varying in prevalence: Centers for Disease Control and Prevention Adult Sepsis Event (4.4%), Centers for Medicare and Medicaid severe sepsis core measure 1 (4.8%), International Classification of Disease code (7.2%), Sepsis-3 (7.5%), and Sepsis-1 (11.3%). Between the two modern established criteria, Sepsis-3 (n = 21,550) and Centers for Disease Control and Prevention Adult Sepsis Event (n = 12,494), the size of the overlap was 7,763. The sepsis cohorts also varied in time from admission to sepsis onset (hr): Sepsis-1 (2.9), Sepsis-3 (4.1), Centers for Disease Control and Prevention Adult Sepsis Event (4.6), and Centers for Medicare and Medicaid severe sepsis core measure 1 (7.6); sepsis discharge International Classification of Disease code rate: Sepsis-1 (37.4%), Sepsis-3 (40.1%), Centers for Medicare and Medicaid severe sepsis core measure 1 (48.5%), and Centers for Disease Control and Prevention Adult Sepsis Event (54.5%); and inhospital mortality rate: Sepsis-1 (13.6%), Sepsis-3 (18.8%), International Classification of Disease code (20.4%), Centers for Medicare and Medicaid severe sepsis core measure 1 (22.5%), and Centers for Disease Control and Prevention Adult Sepsis Event (24.1%). CONCLUSIONS The application of commonly used sepsis definitions on a single population produced sepsis cohorts with low agreement, significantly different baseline demographics, and clinical outcomes.
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14
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Chen L, Zheng H, Chen L, Wu S, Wang S. National Early Warning Score in Predicting Severe Adverse Outcomes of Emergency Medicine Patients: A Retrospective Cohort Study. J Multidiscip Healthc 2021; 14:2067-2078. [PMID: 34385819 PMCID: PMC8354023 DOI: 10.2147/jmdh.s324068] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Accepted: 07/21/2021] [Indexed: 12/28/2022] Open
Abstract
Background For emergency triage, it is very important to identify patient severity according to their vital signs and chief complaint. Several studies have examined the predictive value of the National Early Warning Score (NEWS) for specific emergency patients and have shown it to be effective. However, few have studied the utility of NEWS in emergency triage for general emergency medicine patients. The aim of this research was to investigate the performance of NEWS in emergency triage with regard to predicting adverse outcomes. Methods This was a retrospective cohort study carried out at a tertiary care center hospital in Jinhua, China. A total of 62,403 patients attending the emergency department (ED) from January to December 2018 were included. The NEWS, Modified Early Warning Score (MEWS), and quick Sepsis Related Organ Failure Assessment (qSOFA) score were obtained from emergency triage. Multivariate logistic regression analysis was performed to evaluate the associations between the NEWS, MEWS, and qSOFA, as well as those between other parameters with ED mortality. The predictive performances for emergency observation, death, and intensive care unit (ICU) admission of NEWS, MEWS and qSOFA were compared to the area under the receiver operating characteristic curve (AUROC). Results Of the total participants, 6502 were placed under emergency observation, 106 died in the ED, 638 were admitted to the ICU, and 324 died in-hospital. The NEWS, qSOFA, age, and gender were significantly associated with ED mortality. NEWS was significantly better at discriminating all outcomes, and the area under the curve and 95% confidence intervals for ED mortality, observation in ED, composite of ED mortality and ICU admission, and in-hospital mortality were 0.862 (0.859-0.865), 0.691 (0.687-0.695), 0.859 (0.856-0.861), and 0.805 (0.802-0.808), respectively. Conclusion NEWS shows good performance in discriminating critical emergency patients in ED triage for emergency medicine patients.
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Affiliation(s)
- Lan Chen
- Nursing Education Department, Affiliated Jinhua Hospital, Zhejiang University School of Medicine, Jinhua Municipal Central Hospital, Jinhua, Zhejiang Province, People's Republic of China
| | - Han Zheng
- Emergency Department, Affiliated Jinhua Hospital, Zhejiang University School of Medicine, Jinhua Municipal Central Hospital, Jinhua, Zhejiang Province, People's Republic of China
| | - Lijun Chen
- Emergency Department, Affiliated Jinhua Hospital, Zhejiang University School of Medicine, Jinhua Municipal Central Hospital, Jinhua, Zhejiang Province, People's Republic of China
| | - Sunying Wu
- Emergency Department, Affiliated Jinhua Hospital, Zhejiang University School of Medicine, Jinhua Municipal Central Hospital, Jinhua, Zhejiang Province, People's Republic of China
| | - Saibin Wang
- Department of Respiratory Medicine, Affiliated Jinhua Hospital, Zhejiang University School of Medicine, Jinhua Municipal Central Hospital, Jinhua, 321000, Zhejiang Province, People's Republic of China
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15
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Clinical prediction of bacteremia and early antibiotics therapy in patients with solid tumors. Infect Control Hosp Epidemiol 2021; 43:1112-1118. [PMID: 34315562 DOI: 10.1017/ice.2021.314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE To investigate the relationship between the systemic inflammatory response syndrome (SIRS), early antibiotic use, and bacteremia in solid-tumor patients. DESIGN, SETTING, AND PARTICIPANTS We conducted a retrospective observational study of adults with solid tumors admitted to a tertiary-care hospital through the emergency department over a 2-year period. Patients with neutropenic fever, organ transplant, trauma, or cardiopulmonary arrest were excluded. METHODS Rates of SIRS, bacteremia, and early antibiotics (initiation within 8 hours of presentation) were compared using the χ2 and Student t tests. Binomial regression and receiver operator curves were analyzed to assess predictors of bacteremia and early antibiotics. RESULTS Early antibiotics were administered in 507 (37%) of 1,344 SIRS-positive cases and 492 (22%) of 2,236 SIRS-negative cases (P < .0001). Of SIRS-positive cases, 70% had blood cultures drawn within 48 hours and 19% were positive; among SIRS negative cases, 35% had cultures and 13% were positive (19% vs 13%; P = .003). Bacteremic cases were more often SIRS positive than nonbacteremic cases (60% vs 50%; P =.003), but they received early antibiotics at similar rates (50% vs 49%, P = .72). Three SIRS components predicted early antibiotics: temperature (OR, 1.7; 95% CI, 1.31-2.29; P = .0001), tachycardia (OR, 1.4; 95% CI, 1.10-1.69; P < .0001), and white blood-cell count (OR, 1.8; 95% CI, 1.56-2.14; P < .0001). Only temperature (OR, 1.6; 95% CI, 1.09-2.41; P = .01) and tachycardia (OR, 1.5; 95% CI, 1.09-2.06; P = .01) predicted bacteremia. SIRS criteria as a composite were poorly predictive of bacteremia (AUC, 0.57). CONCLUSIONS SIRS criteria are frequently used to determine the need for early antibiotics, but they are poor predictors of bacteremia in solid-tumor patients. More reliable models are needed to guide judicious use of antibiotics in this population.
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16
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Monocyte Distribution Width, Neutrophil-to-Lymphocyte Ratio, and Platelet-to-Lymphocyte Ratio Improves Early Prediction for Sepsis at the Emergency. J Pers Med 2021; 11:jpm11080732. [PMID: 34442376 PMCID: PMC8402196 DOI: 10.3390/jpm11080732] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 07/24/2021] [Accepted: 07/27/2021] [Indexed: 12/19/2022] Open
Abstract
(1) Background: Sepsis is a life-threatening condition, and most patients with sepsis first present to the emergency department (ED) where early identification of sepsis is challenging due to the unavailability of an effective diagnostic model. (2) Methods: In this retrospective study, patients aged ≥20 years who presented to the ED of an academic hospital with systemic inflammatory response syndrome (SIRS) were included. The SIRS, sequential organ failure assessment (SOFA), and quick SOFA (qSOFA) scores were obtained for all patients. Routine complete blood cell testing in conjugation with the examination of new inflammatory biomarkers, namely monocyte distribution width (MDW), neutrophil-to-lymphocyte ratio (NLR), and platelet-to-lymphocyte ratio (PLR), was performed at the ED. Propensity score matching was performed between patients with and without sepsis. Logistic regression was used for constructing models for early sepsis prediction. (3) Results: We included 296 patients with sepsis and 1184 without sepsis. A SIRS score of >2, a SOFA score of >2, and a qSOFA score of >1 showed low sensitivity, moderate specificity, and limited diagnostic accuracy for predicting early sepsis infection (c-statistics of 0.660, 0.576, and 0.536, respectively). MDW > 20, PLR > 9, and PLR > 210 showed higher sensitivity and moderate specificity. When we combined these biomarkers and scoring systems, we observed a significant improvement in diagnostic performance (c-statistics of 0.796 for a SIRS score of >2, 0.761 for a SOFA score of >2, and 0.757 for a qSOFA score of >1); (4) Conclusions: The new biomarkers MDW, NLR, and PLR can be used for the early detection of sepsis in the current sepsis scoring systems.
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17
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Sheikh Z, Tan ET, Ifedayo S, Quraishi MS. The role of sepsis screening, SIRS and qSOFA in head and neck infections: An audit of 104 patients. Clin Otolaryngol 2021; 46:1273-1277. [PMID: 34174167 DOI: 10.1111/coa.13828] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Revised: 04/01/2021] [Accepted: 05/15/2021] [Indexed: 12/01/2022]
Affiliation(s)
- Zain Sheikh
- Department of Otolaryngology, Head and Neck Surgery, Doncaster Royal Infirmary, Doncaster, UK.,University of Sheffield, Sheffield, UK
| | - E Tian Tan
- Department of Otolaryngology, Head and Neck Surgery, Doncaster Royal Infirmary, Doncaster, UK
| | - Sunday Ifedayo
- Primary Care, West End Lane Clinic, Doncaster Royal Infirmary, Doncaster, UK
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18
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Loots FJ, Smulders D, Giesen P, Hopstaken RM, Smits M. Vital signs of the systemic inflammatory response syndrome in adult patients with acute infections presenting in out-of-hours primary care: A cross-sectional study. Eur J Gen Pract 2021; 27:83-89. [PMID: 33978531 PMCID: PMC8118397 DOI: 10.1080/13814788.2021.1917544] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Background Signs of the systemic inflammatory response syndrome (SIRS) – fever (or hypothermia), tachycardia and tachypnoea – are used in the hospital setting to identify patients with possible sepsis. Objectives To determine how frequently abnormalities in the vital signs of SIRS are present in adult out-of-hours (OOH) primary care patients with suspected infections and assess the association with acute hospital referral. Methods We conducted a cross-sectional study at the OOH GP cooperative in Nijmegen, the Netherlands, between August and October 2015. GPs were instructed to record the body temperature, heart rate and respiratory rate of all patients with suspected acute infections. Vital signs of SIRS, other relevant signs and symptoms, and referral state were extracted from the electronic registration system of the OOH GP cooperative retrospectively. Logistic regression analysis was used to evaluate the association between clinical signs and hospital referral. Results A total of 558 patients with suspected infections were included. At least two SIRS vital signs were abnormal in 35/409 (8.6%) of the clinic consultations and 60/149 (40.3%) of the home visits. Referral rate increased from 13% when no SIRS vital sign was abnormal to 68% when all three SIRS vital signs were abnormal. Independent associations for referral were found for decreased oxygen saturation, hypotension and rapid illness progression, but not for individual SIRS vital signs. Conclusion Although patients with abnormal vital signs of SIRS were referred more often, decreased oxygen saturation, hypotension and rapid illness progression seem to be most important for GPs to guide further management.
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Affiliation(s)
- Feike J Loots
- Scientific Centre for Quality of Healthcare (IQ healthcare), Radboud University Medical Centre, Radboud Institute for Health Sciences, Nijmegen, The Netherlands.,Julius Center for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Daan Smulders
- Scientific Centre for Quality of Healthcare (IQ healthcare), Radboud University Medical Centre, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | - Paul Giesen
- Scientific Centre for Quality of Healthcare (IQ healthcare), Radboud University Medical Centre, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | | | - Marleen Smits
- Scientific Centre for Quality of Healthcare (IQ healthcare), Radboud University Medical Centre, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
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Siddiqui M, Abuelroos D, Qu L, Jackson RE, Berger DA. Emergency Department Urosepsis and Abdominal Imaging. Cureus 2021; 13:e14752. [PMID: 34084678 PMCID: PMC8164387 DOI: 10.7759/cureus.14752] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Introduction Insufficient attention has been directed towards urosepsis. Notably, no protocols or clinical decision rules currently exist outlining the appropriate use of imaging in uroseptic patients. The primary objective of our study was to retrospectively evaluate uroseptic emergency department (ED) patients who underwent abdominal imaging, to report the proportion of patients with imaging findings necessitating emergent surgical consultation. Methods We retrospectively identified 1142 patients ≥ 18 years of age that presented to the ED from January 2009 to December 2012 with ICD9 code indicative of urosepsis. All included patients underwent ED-ordered abdominal computerized tomography (CT) or retroperitoneal ultrasound (US). Imaging and urinalysis (UA) results were categorized. We report proportions with odds ratios and 95% confidence intervals. Results Of 1142 patients, we excluded 80 for neg UA, 167 for < 2 SIRS (systemic inflammatory response syndrome), 320 for positive blood cultures, and 37 for incomplete data. This yielded 538 patients which the authors reviewed the results of the CT or US to determine the proportion who required emergent surgical consultation and who underwent surgical or interventional procedure. There were 243 (45%) that had CT or US results that necessitated emergency surgical consultation, of those 180 (33%) underwent surgical or interventional procedure. Similar rates of emergency surgical consultation occurred when sub-divided by positive versus equivocal UA, with 43% and 47%, respectively. Conclusions Forty-five percent of our abdominally imaged urosepsis cohort had imaging findings that necessitated emergent surgical consultation, with a similar proportion in the subset with positive versus equivocal UA. The utility of abdominal imaging in this population should be studied prospectively.
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Affiliation(s)
| | | | - Lihua Qu
- Research, Beaumont Health, Royal Oak, MI, USA
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20
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Koch C, Edinger F, Fischer T, Brenck F, Hecker A, Katzer C, Markmann M, Sander M, Schneck E. Comparison of qSOFA score, SOFA score, and SIRS criteria for the prediction of infection and mortality among surgical intermediate and intensive care patients. World J Emerg Surg 2020; 15:63. [PMID: 33239088 PMCID: PMC7687806 DOI: 10.1186/s13017-020-00343-y] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Accepted: 11/05/2020] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND It is crucial to rapidly identify sepsis so that adequate treatment may be initiated. Accordingly, the Sequential Organ Failure Assessment (SOFA) and the quick SOFA (qSOFA) scores are used to evaluate intensive care unit (ICU) and non-ICU patients, respectively. As demand for ICU beds rises, the intermediate care unit (IMCU) carries greater importance as a bridge between the ICU and the regular ward. This study aimed to examine the ability of SOFA and qSOFA scores to predict suspected infection and mortality in IMCU patients. METHODS Retrospective data analysis included 13,780 surgical patients treated at the IMCU, ICU, or both between January 01, 2012, and September 30, 2018. Patients were screened for suspected infection (i.e., the commencement of broad-spectrum antibiotics) and then evaluated for the SOFA score, qSOFA score, and the 1992 defined systemic inflammatory response syndrome (SIRS) criteria. RESULTS Suspected infection was detected in 1306 (18.3%) of IMCU, 1365 (35.5%) of ICU, and 1734 (62.0%) of IMCU/ICU encounters. Overall, 458 (3.3%) patients died (IMCU 45 [0.6%]; ICU 250 [6.5%]; IMCU/ICU 163 [5.8%]). All investigated scores failed to predict suspected infection independently of the analyzed subgroup. Regarding mortality prediction, the qSOFA score performed sufficiently within the IMCU cohort (AUCROC SIRS 0.72 [0.71-0.72]; SOFA 0.52 [0.51-0.53]; qSOFA 0.82 [0.79-0.84]), while the SOFA score was predictive in patients of the IMCU/ICU cohort (AUCROC SIRS 0.54 [0.53-0.54]; SOFA 0.73 [0.70-0.77]; qSOFA 0.59 [0.58-0.59]). CONCLUSIONS None of the assessed scores was sufficiently able to predict suspected infection in surgical ICU or IMCU patients. While the qSOFA score is appropriate for mortality prediction in IMCU patients, SOFA score prediction quality is increased in critically ill patients.
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Affiliation(s)
- Christian Koch
- Department of Anesthesiology, Operative Intensive Care Medicine and Pain Therapy, University Hospital of Giessen, Rudolf-Buchheim-Street 7, 35392, Giessen, Germany. .,German Center of Infection Research (DZIF), Partner Site Giessen/Marburg/Langen, Giessen, Germany.
| | - Fabian Edinger
- Department of Anesthesiology, Operative Intensive Care Medicine and Pain Therapy, University Hospital of Giessen, Rudolf-Buchheim-Street 7, 35392, Giessen, Germany.,German Center of Infection Research (DZIF), Partner Site Giessen/Marburg/Langen, Giessen, Germany
| | - Tobias Fischer
- Department of Anesthesiology, Operative Intensive Care Medicine and Pain Therapy, University Hospital of Giessen, Rudolf-Buchheim-Street 7, 35392, Giessen, Germany
| | - Florian Brenck
- Department of Anesthesiology, Operative Intensive Care Medicine and Pain Therapy, University Hospital of Giessen, Rudolf-Buchheim-Street 7, 35392, Giessen, Germany
| | - Andreas Hecker
- Department of General and Thoracic Surgery, University Hospital of Giessen, Giessen, Germany
| | - Christian Katzer
- Department of Anesthesiology, Operative Intensive Care Medicine and Pain Therapy, University Hospital of Giessen, Rudolf-Buchheim-Street 7, 35392, Giessen, Germany
| | - Melanie Markmann
- Department of Anesthesiology, Operative Intensive Care Medicine and Pain Therapy, University Hospital of Giessen, Rudolf-Buchheim-Street 7, 35392, Giessen, Germany
| | - Michael Sander
- Department of Anesthesiology, Operative Intensive Care Medicine and Pain Therapy, University Hospital of Giessen, Rudolf-Buchheim-Street 7, 35392, Giessen, Germany.,German Center of Infection Research (DZIF), Partner Site Giessen/Marburg/Langen, Giessen, Germany
| | - Emmanuel Schneck
- Department of Anesthesiology, Operative Intensive Care Medicine and Pain Therapy, University Hospital of Giessen, Rudolf-Buchheim-Street 7, 35392, Giessen, Germany.,German Center of Infection Research (DZIF), Partner Site Giessen/Marburg/Langen, Giessen, Germany
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21
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Perman SM, Mikkelsen ME, Goyal M, Ginde A, Bhardwaj A, Drumheller B, Sante SC, Agarwal AK, Gaieski DF. The sensitivity of qSOFA calculated at triage and during emergency department treatment to rapidly identify sepsis patients. Sci Rep 2020; 10:20395. [PMID: 33230117 PMCID: PMC7683594 DOI: 10.1038/s41598-020-77438-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Accepted: 11/11/2020] [Indexed: 12/12/2022] Open
Abstract
The quick sequential organ failure assessment (qSOFA) score has been proposed as a means to rapidly identify adult patients with suspected infection, in pre-hospital, Emergency Department (ED), or general hospital ward locations, who are in a high-risk category with increased likelihood of "poor outcomes:" a greater than 10% chance of dying or an increased likelihood of spending 3 or more days in the ICU. This score is intended to replace the use of systemic inflammatory response syndrome (SIRS) criteria as a screening tool; however, its role in ED screening and identification has yet to be fully elucidated. In this retrospective observational study, we explored the performance of triage qSOFA (tqSOFA), maximum qSOFA, and first initial serum lactate (> 3 mmol/L) at predicting in-hospital mortality and compared these results to those for the initial SIRS criteria obtained in triage. A total of 2859 sepsis cases were included and the in-hospital mortality rate was 14.4%. The sensitivity of tqSOFA ≥ 2 and maximum qSOFA ≥ 2 to predict in-hospital mortality were 33% and 69%, respectively. For comparison, the triage SIRS criteria and the initial lactate > 3 mmol/L had sensitivities of 82% and 65%, respectively. These results demonstrate that in a large ED sepsis database the earliest measurement of end organ impairment, tqSOFA, performed poorly at identifying patients at increased risk of mortality and maximum qSOFA did not significantly outperform initial serum lactate levels.
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Affiliation(s)
- Sarah M Perman
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, USA
| | - Mark E Mikkelsen
- Division of Pulmonary and Critical Care Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, USA
| | - Munish Goyal
- Departments of Emergency and Critical Care Medicine, MedSTAR Washington Hospital Centre, Washington, USA
| | - Adit Ginde
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, USA
| | - Abhishek Bhardwaj
- Division of Critical Care Medicine, Cleveland Clinic Department of Internal Medicine, Cleveland, USA
| | - Byron Drumheller
- Department of Emergency Medicine, Albert Einstein Medical Center, Philadelphia, USA
| | - S Cham Sante
- Department of Emergency Medicine, University of New Mexico School of Medicine, Philadelphia, USA
| | - Anish K Agarwal
- Department of Emergency Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, USA
| | - David F Gaieski
- Department of Emergency Medicine, Vice Chair for Resuscitation Services, Director of Emergency Critical Care, Enterprise Physician Lead for Sepsis Care, Sidney Kimmel Medical College at Thomas Jefferson University, 1025 Walnut Street; 300 College Building, Philadelphia, PA, 19107, USA.
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Potential Lipid Signatures for Diagnosis and Prognosis of Sepsis and Systemic Inflammatory Response Syndrome. Metabolites 2020; 10:metabo10090359. [PMID: 32882869 PMCID: PMC7570015 DOI: 10.3390/metabo10090359] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 08/19/2020] [Accepted: 08/26/2020] [Indexed: 02/06/2023] Open
Abstract
Systemic inflammatory response syndrome (SIRS) and sepsis are two conditions which are difficult to differentiate clinically and which are strongly impacted for prompt intervention. This study identified potential lipid signatures that are able to differentiate SIRS from sepsis and to predict prognosis. Forty-two patients, including 21 patients with sepsis and 21 patients with SIRS, were involved in the study. Liquid chromatography coupled to mass spectrometry and multivariate statistical methods were used to determine lipids present in patient plasma. The obtained lipid signatures revealed 355 features for the negative ion mode and 297 for the positive ion mode, which were relevant for differential diagnosis of sepsis and SIRS. These lipids were also tested as prognosis predictors. Lastly, L-octanoylcarnitine was found to be the most promising lipid signature for both the diagnosis and prognosis of critically ill patients, with accuracies of 75% for both purposes. In short, we presented the determination of lipid signatures as a potential tool for differential diagnosis of sepsis and SIRS and prognosis of these patients.
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