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Kralovcova M, Müller J, Hajsmanova Z, Sigutova P, Bultasova L, Palatova J, Matejovic M. Understanding the value of monocyte distribution width (MDW) in acutely ill medical patients presenting to the emergency department: a prospective single center evaluation. Sci Rep 2024; 14:15255. [PMID: 38956252 PMCID: PMC11219845 DOI: 10.1038/s41598-024-65883-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2024] [Accepted: 06/25/2024] [Indexed: 07/04/2024] Open
Abstract
The monocyte distribution width (MDW) has emerged as a promising biomarker for accurate and early identification of patients with potentially life-threatening infections. Here we tested the diagnostic performance of MDW in adult patients requiring hospital admission for community-acquired infections and sepsis, evaluated sources of heterogeneity in the estimates of diagnostic accuracy, and assessed the meaning of MDW in a patient population presenting to the emergency department (ED) for acute non-infectious conditions. 1925 consecutive patients were categorized into three groups: non-infection (n = 1507), infection (n = 316), and sepsis/septic shock (n = 102). Diagnostic performance for infection or sepsis of MDW alone or in combination with components of SOFA was tested using AUC of ROC curves, sensitivity, and specificity. The relationship between MDW and different pathogens as well as the impact of non-infectious conditions on MDW values were explored. For the prediction of infection, the AUC/ROC of MDW (0.84) was nearly overlapping that of procalcitonin (0.83), and C-reactive protein (0.89). Statistical optimal cut-off value for MDW was 21 for predicting infection (sensitivity 73%, specificity 82%) and 22 for predicting sepsis (sensitivity 79%, specificity 83%). The best threshold to rule out infection was MDW ≤ 17 (NPV 96.9, 95% CI 88.3-100.0), and ≤ 18 (NPV 99.5, 95% CI 98.3-100.0) to rule out sepsis. The combination of MDW with markers of organ dysfunction (creatinine, bilirubin, platelets) substantially improved the AUC (0.96 (95% CI 0.94-0.97); specificity and sensitivity of 88% and 94%, respectively). In conclusion, MDW has a good diagnostic performance in diagnosing infection and sepsis in patients presenting in ED. Its use as an infection marker even increases when combined with other markers of organ dysfunction. Understanding the impact of interactions of non-infectious conditions and comorbidities on MDW and its diagnostic accuracy requires further elucidation.
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Affiliation(s)
- Marcela Kralovcova
- 1st Department of Internal Medicine, Faculty of Medicine in Pilsen, Teaching Hospital, Charles University, Prague, alej Svobody 80, 323 00, Pilsen, Czech Republic
| | - Jiri Müller
- 1st Department of Internal Medicine, Faculty of Medicine in Pilsen, Teaching Hospital, Charles University, Prague, alej Svobody 80, 323 00, Pilsen, Czech Republic
| | - Zdenka Hajsmanova
- Institute of Clinical Biochemistry and Hematology, Faculty of Medicine in Pilsen, Teaching Hospital, Charles University, Prague, alej Svobody 80, 323 00, Pilsen, Czech Republic
| | - Pavla Sigutova
- Institute of Clinical Biochemistry and Hematology, Faculty of Medicine in Pilsen, Teaching Hospital, Charles University, Prague, alej Svobody 80, 323 00, Pilsen, Czech Republic
| | - Lenka Bultasova
- Institute of Clinical Biochemistry and Hematology, Faculty of Medicine in Pilsen, Teaching Hospital, Charles University, Prague, alej Svobody 80, 323 00, Pilsen, Czech Republic
| | - Jana Palatova
- Institute of Clinical Biochemistry and Hematology, Faculty of Medicine in Pilsen, Teaching Hospital, Charles University, Prague, alej Svobody 80, 323 00, Pilsen, Czech Republic
| | - Martin Matejovic
- 1st Department of Internal Medicine, Faculty of Medicine in Pilsen, Teaching Hospital, Charles University, Prague, alej Svobody 80, 323 00, Pilsen, Czech Republic.
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Lengquist M, Varadarajan A, Alestam S, Friberg H, Frigyesi A, Mellhammar L. Sepsis mimics among presumed sepsis patients at intensive care admission: a retrospective observational study. Infection 2024; 52:1041-1053. [PMID: 38280062 DOI: 10.1007/s15010-023-02158-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Accepted: 12/12/2023] [Indexed: 01/29/2024]
Abstract
BACKGROUND Diagnosing sepsis remains a challenge because of the lack of gold-standard diagnostics. Since there are no simple, broadly accepted criteria for infection, there is a risk of misclassifying sepsis patients (sepsis mimics) among patients with organ failure. The main objective of this study was to investigate the proportion of non-infected patients (sepsis mimics) in ICU patients with presumed sepsis at intensive care unit (ICU) admission. METHODS Adult patients were screened retrospectively during 3.5 years in four ICUs in Sweden for fulfilment of the sepsis-3 criteria at ICU admission (presumed sepsis). Proxy criteria for suspected infection were sampled blood culture(s) and concomitant antibiotic administration. Culture-negative presumed sepsis patients were screened for infection according to the Linder-Mellhammar Criteria of Infection (LMCI). Sepsis mimics were defined as without probable infection according to the LMCI. Confirmed sepsis was defined as presumed sepsis after the exclusion of sepsis mimics. RESULTS In the ICU presumed sepsis cohort (2664 patients), 25% were considered sepsis mimics. The most common reasons for ICU admission among sepsis mimics were acute heart failure and unspecific respiratory failure. Comparing sepsis mimics and confirmed sepsis showed that confirmed sepsis patients were slightly more severely ill but had similar mortality. C-reactive protein had modest discriminatory power (AUROC 0.71) with confirmed sepsis as the outcome. CONCLUSIONS One-fourth of a presumed ICU sepsis population identified with the sepsis-3 criteria could be considered sepsis mimics. The high proportion of sepsis mimics has a potential dilutional effect on the presumed sepsis population, which threatens the validity of results from sepsis studies using recommended sepsis criteria.
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Affiliation(s)
- Maria Lengquist
- Department of Clinical Medicine, Lund University, Lund, Sweden.
- Department of Anaesthesia and Intensive Care, Skåne University Hospital, Lund, Sweden.
| | - Anjali Varadarajan
- Department of Clinical Medicine, Lund University, Lund, Sweden
- Department of Anaesthesia and Intensive Care, Skåne University Hospital, Lund, Sweden
| | - Shiva Alestam
- Department of Clinical Medicine, Lund University, Lund, Sweden
- Department of Anaesthesia and Intensive Care, Skåne University Hospital, Lund, Sweden
| | - Hans Friberg
- Department of Clinical Medicine, Lund University, Lund, Sweden
- Department of Anaesthesia and Intensive Care, Skåne University Hospital, Malmö, Sweden
| | - Attila Frigyesi
- Department of Clinical Medicine, Lund University, Lund, Sweden
- Department of Anaesthesia and Intensive Care, Skåne University Hospital, Lund, Sweden
| | - Lisa Mellhammar
- Department of Clinical Medicine, Lund University, Lund, Sweden
- Department of Infectious Diseases, Skåne University Hospital, Lund, Sweden
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Mellhammar L, Wollter E, Dahlberg J, Donovan B, Olséen CJ, Wiking PO, Rose N, Schwarzkopf D, Friedrich M, Fleischmann-Struzek C, Reinhart K, Linder A. Estimating Sepsis Incidence Using Administrative Data and Clinical Medical Record Review. JAMA Netw Open 2023; 6:e2331168. [PMID: 37642964 PMCID: PMC10466163 DOI: 10.1001/jamanetworkopen.2023.31168] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Accepted: 07/11/2023] [Indexed: 08/31/2023] Open
Abstract
Importance Despite the large health burden, reliable data on sepsis epidemiology are lacking; studies using International Statistical Classification of Diseases and Related Health Problems (ICD)-coded hospital discharge diagnosis for sepsis identification suffer from limited sensitivity. Also, ICD data do not allow investigation of underlying pathogens and antimicrobial resistance. Objectives To generate reliable epidemiological estimates by linking data from a population-based database to a reference standard of clinical medical record review. Design, Setting, and Participants This was a retrospective, observational cohort study using a population-based administrative database including all acute care hospitals of the Scania region in Sweden in 2019 and 2020 to identify hospital-treated sepsis cases by ICD codes. From this database, clinical medical records were also selected for review within 6 strata defined by ICD discharge diagnosis (both with and without sepsis diagnosis). Data were analyzed from April to October 2022. Main outcomes and measures Hospital and population incidences of sepsis, case fatality, antimicrobial resistance, and temporal dynamics due to COVID-19 were assessed, as well as validity of ICD-10 case identification methods compared with the reference standard of clinical medical record review. Results Out of 295 531 hospitalizations in 2019 in the Scania region of Sweden, 997 patient medical records were reviewed, among which 457 had sepsis according to clinical criteria. Of the patients with clinical sepsis, 232 (51%) were female, and 357 (78%) had at least 1 comorbidity. The median (IQR) age of the cohort was 76 (67-85) years. The incidence of sepsis in hospitalized patients according to the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3) criteria in 2019 was 4.1% (95% CI, 3.6-4.5) by medical record review. This corresponds to an annual incidence rate of 747 (95% CI, 663-832) patients with sepsis per 100 000 population. No significant increase in sepsis during the COVID-19 pandemic nor a decrease in sepsis incidence when excluding COVID-19 sepsis was observed. Few sepsis cases caused by pathogens with antimicrobial resistance were found. The validity of ICD-10-based case identification in administrative data was low. Conclusions and Relevance In this cohort study of sepsis epidemiology, sepsis was a considerable burden to public health in Sweden. Supplying administrative data with information from clinical medical records can help to generate reliable data on sepsis epidemiology.
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Affiliation(s)
- Lisa Mellhammar
- Department of Clinical Sciences, Division of Infection Medicine, Lund University, Lund, Sweden
| | - Erik Wollter
- Department of Clinical Sciences, Division of Infection Medicine, Lund University, Lund, Sweden
| | - Jacob Dahlberg
- Department of Clinical Sciences, Division of Infection Medicine, Lund University, Lund, Sweden
| | - Benjamin Donovan
- Department of Clinical Sciences, Division of Infection Medicine, Lund University, Lund, Sweden
| | - Carl-Johan Olséen
- Department of Clinical Sciences, Division of Infection Medicine, Lund University, Lund, Sweden
| | - Per Ola Wiking
- Department of Clinical Sciences, Division of Infection Medicine, Lund University, Lund, Sweden
| | - Norman Rose
- Institute of Infectious Diseases and Infection Control, Jena University Hospital, Jena, Germany
| | - Daniel Schwarzkopf
- Institute of Infectious Diseases and Infection Control, Jena University Hospital, Jena, Germany
| | - Marcus Friedrich
- Berlin Institute of Health, Campus Virchow-Klinikum, Berlin, Germany
- Stiftung Charité, Berlin, Germany
| | | | - Konrad Reinhart
- Institute of Infectious Diseases and Infection Control, Jena University Hospital, Jena, Germany
- Berlin Institute of Health, Campus Virchow-Klinikum, Berlin, Germany
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany
| | - Adam Linder
- Department of Clinical Sciences, Division of Infection Medicine, Lund University, Lund, Sweden
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de Mul N, Verlaan D, Ruurda JP, van Grevenstein WMU, Hagendoorn J, de Borst GJ, Vriens MR, de Bree R, Zweemer RP, Vogely C, Haitsma Mulier JLG, Vernooij LM, Reitsma JB, de Zoete MR, Top J, Kluijtmans JAJ, Hoefer IE, Noordzij P, Rettig T, Marsman M, de Smet AMGA, Derde L, van Waes J, Rijsdijk M, Schellekens WJM, Bonten MJM, Slooter AJC, Cremer OL. Cohort profile of PLUTO: a perioperative biobank focusing on prediction and early diagnosis of postoperative complications. BMJ Open 2023; 13:e068970. [PMID: 37076142 PMCID: PMC10124280 DOI: 10.1136/bmjopen-2022-068970] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/21/2023] Open
Abstract
PURPOSE Although elective surgery is generally safe, some procedures remain associated with an increased risk of complications. Improved preoperative risk stratification and earlier recognition of these complications may ameliorate postoperative recovery and improve long-term outcomes. The perioperative longitudinal study of complications and long-term outcomes (PLUTO) cohort aims to establish a comprehensive biorepository that will facilitate research in this field. In this profile paper, we will discuss its design rationale and opportunities for future studies. PARTICIPANTS Patients undergoing elective intermediate to high-risk non-cardiac surgery are eligible for enrolment. For the first seven postoperative days, participants are subjected to daily bedside visits by dedicated observers, who adjudicate clinical events and perform non-invasive physiological measurements (including handheld spirometry and single-channel electroencephalography). Blood samples and microbiome specimens are collected at preselected time points. Primary study outcomes are the postoperative occurrence of nosocomial infections, major adverse cardiac events, pulmonary complications, acute kidney injury and delirium/acute encephalopathy. Secondary outcomes include mortality and quality of life, as well as the long-term occurrence of psychopathology, cognitive dysfunction and chronic pain. FINDINGS TO DATE Enrolment of the first participant occurred early 2020. During the inception phase of the project (first 2 years), 431 patients were eligible of whom 297 patients consented to participate (69%). Observed event rate was 42% overall, with the most frequent complication being infection. FUTURE PLANS The main purpose of the PLUTO biorepository is to provide a framework for research in the field of perioperative medicine and anaesthesiology, by storing high-quality clinical data and biomaterials for future studies. In addition, PLUTO aims to establish a logistical platform for conducting embedded clinical trials. TRIAL REGISTRATION NUMBER NCT05331118.
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Affiliation(s)
- Nikki de Mul
- Department of Anaesthesiology, UMC Utrecht, Utrecht, The Netherlands
- Department of Intensive Care Medicine, UMC Utrecht, Utrecht, The Netherlands
- Julius Center, Department of Epidemiology, Program of Infectious Diseases, UMC Utrecht, Utrecht, The Netherlands
| | - Diede Verlaan
- Department of Intensive Care Medicine, UMC Utrecht, Utrecht, The Netherlands
- Julius Center, Department of Epidemiology, Program of Infectious Diseases, UMC Utrecht, Utrecht, The Netherlands
| | - Jelle P Ruurda
- Department of Surgical Oncology, Upper Gastro-Intestinal Surgery, UMC Utrecht, Utrecht, The Netherlands
| | | | - Jeroen Hagendoorn
- Department of Surgical Oncology, Hepatobilliary and Pancreatic Surgery, UMC Utrecht, Utrecht, The Netherlands
| | - Gert-Jan de Borst
- Department of Vascular Surgery, UMC Utrecht, Utrecht, The Netherlands
| | - Menno R Vriens
- Department of Endocrine and Surgical Oncology, Cancer Center, UMC Utrecht, Utrecht, The Netherlands
| | - Remco de Bree
- Department of Head and Neck Surgical Oncology, UMC Utrecht, Utrecht, The Netherlands
| | - Ronald P Zweemer
- Department of Gynaecological Oncology, UMC Utrecht, Utrecht, The Netherlands
| | - Charles Vogely
- Department of Orthopaedic Surgery, UMC Utrecht, Utrecht, The Netherlands
| | - Jelle L G Haitsma Mulier
- Department of Intensive Care Medicine, UMC Utrecht, Utrecht, The Netherlands
- Julius Center, Department of Epidemiology, Program of Infectious Diseases, UMC Utrecht, Utrecht, The Netherlands
| | - Lisette M Vernooij
- Department of Anaesthesiology, UMC Utrecht, Utrecht, The Netherlands
- Department of Intensive Care Medicine, UMC Utrecht, Utrecht, The Netherlands
- Department of Anaesthesiology and Intensive Care, Antonius Ziekenhuis Nieuwegein, Nieuwegein, The Netherlands
| | - Johannes B Reitsma
- Julius Center for Health Sciences and Primary Care, UMC Utrecht, Utrecht, The Netherlands
| | - Marcel R de Zoete
- Department of Medical Microbiology, UMC Utrecht, Utrecht, The Netherlands
| | - Janetta Top
- Department of Medical Microbiology, UMC Utrecht, Utrecht, The Netherlands
| | - Jan A J Kluijtmans
- Department of Medical Microbiology, UMC Utrecht, Utrecht, The Netherlands
| | - Imo E Hoefer
- Central Diagnostic Laboratory, Universitair Medisch Centrum, Utrecht, The Netherlands
| | - Peter Noordzij
- Department of Anaesthesiology and Intensive Care, Antonius Ziekenhuis Nieuwegein, Nieuwegein, The Netherlands
| | - Thijs Rettig
- Department of Anesthesiology, Intensive Care and Pain Medicine, Amphia Hospital site Molengracht, Breda, The Netherlands
| | - Marije Marsman
- Department of Anaesthesiology, UMC Utrecht, Utrecht, The Netherlands
| | | | - Lennie Derde
- Department of Intensive Care Medicine, UMC Utrecht, Utrecht, The Netherlands
| | - Judith van Waes
- Department of Anaesthesiology, UMC Utrecht, Utrecht, The Netherlands
| | - Mienke Rijsdijk
- Department of Anaesthesiology, UMC Utrecht, Utrecht, The Netherlands
| | - Willem Jan M Schellekens
- Department of Anaesthesiology, UMC Utrecht, Utrecht, The Netherlands
- Department of Anaesthesiology, Cantonal Hospital Aarau, Aarau, Switzerland
| | - Marc J M Bonten
- Julius Center, Department of Epidemiology, Program of Infectious Diseases, UMC Utrecht, Utrecht, The Netherlands
| | - Arjen J C Slooter
- Department of Intensive Care Medicine, UMC Utrecht, Utrecht, The Netherlands
| | - Olaf L Cremer
- Department of Intensive Care Medicine, UMC Utrecht, Utrecht, The Netherlands
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Dahlberg J, Linder A, Mellhammar L. Use of healthcare before and after sepsis in Sweden: a case-control study. BMJ Open 2023; 13:e065967. [PMID: 36806063 PMCID: PMC9944643 DOI: 10.1136/bmjopen-2022-065967] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/19/2023] Open
Abstract
OBJECTIVES The aim of this study was to compare readmissions and death between sepsis and non-sepsis hospitalisations the first year after discharge, and to investigate what diagnoses patients with sepsis present with at readmission. The aim was also to evaluate to what degree patients hospitalised for sepsis seek medical attention prior to hospitalisation. DESIGN Retrospective case-control study with data validated through clinical chart review. A disproportionate stratified sampling model was used to include a relatively larger number of sepsis hospitalisations. SETTING All eight public hospitals in region Scania, Sweden (1 January to 3 December 2019). PARTICIPANTS There were 447 patients hospitalised for sepsis (cases), and 541 hospitalised for other causes (control) identified through clinical chart review. OUTCOME MEASURES Cox regression was used to analyse readmission and death the year after discharge, and logistic regression was used to analyse healthcare the week prior to hospitalisation. Both analyses were made unadjusted, and adjusted for age, sex and comorbidities. RESULTS Out of patients who survived a sepsis hospitalisation, 48% were readmitted the year after discharge, compared with 39% for patients without sepsis (HR 1.50, 95% CI 1.03 to 2.19), p=0.04. The majority (52%) of readmissions occurred within 90 days and 75% within 180 days. The readmissions were most often caused by infection (32%), and 18% by cardiovascular disease. Finally, 34% of patients with sepsis had sought prehospital contact with a physician the week before hospitalisation, compared with 22% for patients without sepsis (OR 1.80, 95% CI 1.06 to 3.04), p=0.03. CONCLUSION Patients hospitalised for sepsis had a higher risk of readmission the year after discharge compared with patients without sepsis. The most common diagnoses at readmission were infection followed by cardiovascular disease. With better follow-up, some of these readmissions could potentially be prevented. Patients hospitalised for sepsis had sought prehospital contact the week prior to hospitalisation to a greater extent than patients without sepsis.
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Affiliation(s)
- Jacob Dahlberg
- Division of Infection Medicine, Department of Clinical Sciences, Lund University, Lund, Sweden
| | - Adam Linder
- Division of Infection Medicine, Department of Clinical Sciences, Lund University, Lund, Sweden
| | - Lisa Mellhammar
- Division of Infection Medicine, Department of Clinical Sciences, Lund University, Lund, Sweden
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