Procalcitonin and MR-Proadrenomedullin Combination with SOFA and qSOFA Scores for Sepsis Diagnosis and Prognosis: A Diagnostic Algorithm

Latest developments in early diagnosis and specific treatment of severe influenza infection

Influenza pandemics are unpredictable recurrent events with global health, economic, and social consequences. The objective of this review is to provide an update on the latest developments in early diagnosis and specific treatment of the disease and its complications, particularly with regard to respiratory organ failure. Despite advances in treatment, the rate of mortality in the intensive care unit remains approximately 30%. Therefore, early identification of potentially severe viral pneumonia is extremely important to optimize treatment in these patients. The pathogenesis of influenza virus infection depends on viral virulence and host response. Thus, in some patients, it is associated with an excessive systemic response mediated by an authentic cytokine storm. This process leads to severe primary pneumonia and acute respiratory distress syndrome. Initial prognostication in the emergency department based on comorbidities, vital signs, and biomarkers (e.g., procalcitonin, ferritin, human leukocyte antigen-DR, mid-regional proadrenomedullin, and lactate) is important. Identification of these biomarkers on admission may facilitate clinical decision-making to determine early admission to the hospital or the intensive care unit. These decisions are reached considering pathophysiological circumstances that are associated with a poor prognosis (e.g., bacterial co-infection, hyperinflammation, immune paralysis, severe endothelial damage, organ dysfunction, and septic shock). Moreover, early implementation is important to increase treatment efficacy. Based on a limited level of evidence, all current guidelines recommend using oseltamivir in this setting. The possibility of drug resistance should also be considered. Alternative options include other antiviral drugs and combination therapies with monoclonal antibodies. Importantly, it is not recommended to use corticosteroids in the initial treatment of these patients. Furthermore, the implementation of supportive measures for respiratory failure is essential. Current recommendations are limited, heterogeneous, and not regularly updated. Early intubation and mechanical ventilation is the basic treatment for patients with severe respiratory failure. Prone ventilation should be promptly performed in patients with acute respiratory distress syndrome, while early tracheostomy should be considered in case of planned prolonged mechanical ventilation. Clinical trials on antiviral treatment and respiratory support measures specifically for these patients, as well as specific recommendations for different at-risk populations, are necessary to improve outcomes.

Mid-Regional Pro-Adrenomedullin Can Predict Organ Failure and Prognosis in Sepsis?

Sepsis causes immune dysregulation and endotheliitis, with an increase in mid-regional pro-adrenomedullin (MR-proADM). The aim of the study is to determine an MR-proADM value that, in addition to clinical diagnosis, can identify patients with localized infection or those with sepsis/septic shock, with specific organ damage or with the need for intensive care unit (ICU) transfer and prognosis. The secondary aim is to correlate the MR-proADM value with the length of stay (LOS). In total, 301 subjects with sepsis (124/301 with septic shock) and 126 with localized infection were retrospectively included. In sepsis, MR-proADM ≥ 3.39 ng/mL identified acute kidney injury (AKI); ≥2.99 ng/mL acute respiratory distress syndrome (ARDS); ≥2.28 ng/mL acute heart failure (AHF); ≥2.55 ng/mL Glascow Coma Scale (GCS) < 15; ≥3.38 multi-organ involvement; ≥3.33 need for ICU transfer; ≥2.0 Sequential Organ Failure Assessment (SOFA) score ≥ 2; and ≥3.15 ng/mL non-survivors. The multivariate analysis showed that MR-proADM ≥ 2 ng/mL correlates with AKI, anemia and SOFA score ≥ 2, and MR-proADM ≥ 3 ng/mL correlates with AKI, GCS < 15 and SOFA score ≥ 2. A correlation between mortality and AKI, GCS < 15, ICU transfer and cathecolamine administration was found. In localized infection, MR-proADM at admission ≥ 1.44 ng/mL identified patients with AKI; ≥1.0 ng/mL with AHF; and ≥1.44 ng/mL with anemia and SOFA score ≥ 2. In the multivariate analysis, MR-proADM ≥ 1.44 ng/mL correlated with AKI, anemia, SOFA score ≥ 2 and AHF. MR-proADM is a marker of oxidative stress due to an infection, reflecting severity proportionally to organ damage.

Study of Phospholipase A2 Levels and Its Comparison With Procalcitonin Levels in Patients With Sepsis Admitted in a Tertiary Care Hospital, Karnataka, India

INTRODUCTION

Sepsis is a complicated host response to infection involving organ failure which ultimately causes death of the host. Procalcitonin (PCT) is an effective marker used to diagnose sepsis but until now, there has been no ideal marker for sepsis. Phospholipase A2 (PLA2) also increases infections; however, only a few studies have assessed its capacity as a biomarker to diagnose sepsis. Thus, we aimed to examine PLA2 and compare its diagnostic capacity and accuracy with PCT as a biomarker of sepsis.

MATERIAL AND METHODS

Our study was a hospital-oriented cross-sectional study. Our study group included 80 patients of both sexes older than 18 years, meeting the quick sequential organ failure assessment (qSOFA) or systemic inflammatory response syndrome (SIRS) criteria of ≥2, hospitalized in a tertiary care hospital in Karnataka, India from January 2021 to December 2021. Out of them, 59 were found to have sepsis. Samples of all the patients were evaluated for relevant parameters, and data were statistically analyzed using SPSS v21 running on Windows 10. The statistical significance was set at p-value <0.05.

RESULTS

The mean PCT and PLA2 were significantly raised in sepsis patients compared to non-sepsis patients. Out of 59 septic patients, 45.76% had positive blood cultures, and 16.95% had positive urine culture reports. In blood cultures, the most common Gram-positive organism found was Staphylococcus, and the most common Gram-negative organism was Enterobacter. In urine cultures, Escherichia coli was the most common species. PLA2 was significantly higher in patients with bacterial etiology and Gram-positive cultures. The diagnostic capability, sensitivity, specificity, and accuracy of PLA2 were demonstrably higher than those of PCT.

CONCLUSION

Our study proves that PLA2 is a much better and more efficient biomarker in sepsis than PCT. The diagnostic capacity and accuracy of PLA2 clearly surpass PCT, so using PLA2 in sepsis as a biomarker can help clinicians in deciding on timely and appropriate management to speed the recovery of patients.

Inflammatory biomarkers to predict the prognosis of acute bacterial and viral infections

Mortality in acute infections is mostly associated with sepsis, defined as 'life-threatening organ dysfunction caused by a dysregulated host response to infection'. It remains challenging to identify the patients with increased mortality risk due to the high heterogeneity in the dysregulated host immune response and disease progression. Biomarkers reflecting different pathways involved in the inflammatory response might improve prediction of mortality risk (prognostic enrichment) among patients with acute infections by reducing heterogeneity of the host response, as well as suggest novel strategies for patient stratification and treatment (predictive enrichment) through precision medicine approaches. The predictive value of inflammatory biomarkers has been extensively investigated in bacterial infections and the recent COVID-19 pandemic caused an increased interest in inflammatory biomarkers in this viral infection. However, limited research investigated whether the prognostic potential of these biomarkers differs between bacterial and viral infections. In this narrative review, we provide an overview of the value of various inflammatory biomarkers for the prediction of mortality in bacterial and viral infections.

Identifying Predictors Associated with Risk of Death or Admission to Intensive Care Unit in Internal Medicine Patients with Sepsis: A Comparison of Statistical Models and Machine Learning Algorithms

Background: Sepsis is a time-dependent disease: the early recognition of patients at risk for poor outcome is mandatory. Aim: To identify prognostic predictors of the risk of death or admission to intensive care units in a consecutive sample of septic patients, comparing different statistical models and machine learning algorithms. Methods: Retrospective study including 148 patients discharged from an Italian internal medicine unit with a diagnosis of sepsis/septic shock and microbiological identification. Results: Of the total, 37 (25.0%) patients reached the composite outcome. The sequential organ failure assessment (SOFA) score at admission (odds ratio (OR): 1.83; 95% confidence interval (CI): 1.41-2.39; p < 0.001), delta SOFA (OR: 1.64; 95% CI: 1.28-2.10; p < 0.001), and the alert, verbal, pain, unresponsive (AVPU) status (OR: 5.96; 95% CI: 2.13-16.67; p < 0.001) were identified through the multivariable logistic model as independent predictors of the composite outcome. The area under the receiver operating characteristic curve (AUC) was 0.894; 95% CI: 0.840-0.948. In addition, different statistical models and machine learning algorithms identified further predictive variables: delta quick-SOFA, delta-procalcitonin, mortality in emergency department sepsis, mean arterial pressure, and the Glasgow Coma Scale. The cross-validated multivariable logistic model with the least absolute shrinkage and selection operator (LASSO) penalty identified 5 predictors; and recursive partitioning and regression tree (RPART) identified 4 predictors with higher AUC (0.915 and 0.917, respectively); the random forest (RF) approach, including all evaluated variables, obtained the highest AUC (0.978). All models' results were well calibrated. Conclusions: Although structurally different, each model identified similar predictive covariates. The classical multivariable logistic regression model was the most parsimonious and calibrated one, while RPART was the easiest to interpret clinically. Finally, LASSO and RF were the costliest in terms of number of variables identified.

Comparison of presepsin and Mid-regional pro-adrenomedullin in the diagnosis of sepsis or septic shock: a systematic review and meta-analysis

BACKGROUND

The early diagnosis of sepsis is hampered by the lack of reliable laboratory measures. There is growing evidence that presepsin and Mid-regional pro-adrenomedullin (MR-proADM) are promising biomarkers in the diagnosis of sepsis. This study was conducted to evaluate and compare the diagnostic value of MR-proADM and presepsin in sepsis patients.

METHODS

We searched Web of Science, PubMed, Embase, China national knowledge infrastructure, and Wanfang up to 22th July, 2022, for studies evaluating the diagnosis performance of presepsin and MR-proADM in adult sepsis patients. Risk of bias was assessed using quadas-2. Pooled sensitivity and specificity were calculated using bivariate meta-analysis. Meta-regression and subgroup analysis were used to find source of heterogeneity.

RESULTS

A total of 40 studies were eventually selected for inclusion in this meta-analysis, including 33 for presepsin and seven for MR-proADM. Presepsin had a sensitivity of 0.86 (0.82-0.90), a specificity of 0.79 (0.71-0.85), and an AUC of 0.90 (0.87-0.92). The sensitivity of MR-proADM was 0.84 (0.78-0.88), specificity was 0.86 (0.79-0.91), and AUC was 0.91 (0.88-0.93). The profile of control group, population, and standard reference may be potential sources of heterogeneity.

CONCLUSIONS

This meta-analysis demonstrated that presepsin and MR-proADM exhibited high accuracy (AUC ≥ 0.90) in the diagnosis of sepsis in adults, with MR-proADM showing significantly higher accuracy than presepsin.

Assessment of the Stability of Midregional Proadrenomedullin in Different Biological Matrices

Midregional proadrenomedullin (MR-proADM) has been shown to play a key role in endothelial dysfunction, with increased levels helping to prevent early stages of organ dysfunction. Recent clinical evidence has demonstrated MR-proADM to be a helpful biomarker to identify disease severity in patients with sepsis as well as pneumonia. This biomarker is helpful at triage in emergency departments to assess risk level of patients. The aim of this study is to evaluate the stability of MR-proADM in different biological matrices. The results, obtained by Bland-Altman and scatter plot analyses, demonstrate that deviation of MR-proADM concentration in serum compared to EDTA plasma unequivocally shows that serum should not be used as a sample matrix. Instead, the excellent correlation of heparin plasma vs EDTA plasma samples shows that heparin plasma can be used without reservation in clinical routine and emergency samples.

Predictive values of the SOFA score and procalcitonin for septic shock after percutaneous nephrolithotomy

To investigate the value of combination of the Sequential Organ Failure Assessment (SOFA) score and procalcitonin (PCT) for prediction of septic shock after percutaneous nephrolithotomy (PCNL). A total of 1328 patients receiving PCNL for renal calculi were allocated into control group (without septic shock) and septic shock group, and related data were retrospectively collected. Univariate analysis was firstly performed, and the variables with two sided P < 0.10 were then included in logistic regression analysis to determine independent risk factors. Receiver operating characteristic (ROC) curve was utilized to evaluate the predictive values. Area under curve (AUC) was compared using Z test. Postoperative septic shock was developed in 61 patients (4.6%) and not developed in 1267 patients (95.3%). Multivariate analysis demonstrated that SOFA score (OR: 1.316, 95% CI 1.125–1.922), PCT (OR: 1.205, 95% CI 1.071–1.696) and operative time (OR: 1.108, 95% CI 1.032–1.441) were independent risk factors for septic shock with adjustment for sex, history of urolithiasis surgery, positive history of urine culture and history of PCNL. The ROC curves demonstrated that the AUCs of SOFA score and PCT for predicting septic shock after PCNL were 0.896 (95% CI 0.866–0.927) and 0.792 (95% CI 0.744–0.839), respectively. The AUC of their combination was 0.971 (95% CI 0.949–0.990), which was higher than those of individual predictions (vs 0.896, Z = 4.086, P < 0.001; vs 0.792, Z = 6.983, P < 0.001). Both the SOFA score and PCT could be applied in predicting septic shock after PCNL, and their combination could further elevate the diagnostic ability.

Mid-Regional Pro-Adrenomedullin as a Prognostic Factor for Severe COVID-19 ARDS

Mid-regional proadrenomedullin (MR-proADM) protects against endothelial permeability and has been associated with prognosis in bacterial sepsis. As endothelial dysfunction is central in the pathophysiology of severe SARS-CoV-2 infection, we sought to evaluate MR-proADM both as a prognostic biomarker and as a marker of bacterial superinfection. Consecutive patients admitted to the ICU for severe SARS-CoV-2 pneumonia were prospectively included and serum was bio-banked on days 1, 3, and 7. MR-proADM levels were measured blindly from clinical outcomes in batches at the end of follow-up. Among the 135 patients included between April 2020 and May 2021, 46 (34.1%) had died at day 60. MR-proADM levels on days 1, 3, and 7 were significantly higher in day-60 non-survivors. The area under the curve (AUC) of the receiver operating characteristic (ROC) curve (0.744, p < 0.001) of day-1 MR-proADM compared favorably with the AUC ROC curve of day-1 procalcitonin (0.691, p < 0.001). Serial MR-proADM measurements on days 3 and 7 may add prognostic information. After adjusting for CRP, LDH, and lymphocyte values, day-1 MR-proADM remained significantly associated with day-60 mortality. MR-proADM concentrations were significantly higher in patients with respiratory superinfections (on days 3 and 7) and bloodstream infections (on days 1, 3, and 7) than in patients without infection. Our results suggest that MR-proADM is a good predictor of outcome in severe SARS-CoV-2 infection and could be a useful tool to assess bacterial superinfection in COVID-19 patients.

Performance of presepsin and procalcitonin predicting culture-proven bacterial infection and 28-day mortality: A cross sectional study

Presepsin is a highly specific biomarker for diagnosing bacterial infections, but its clinical usefulness is not well validated. A retrospective cross-sectional study was conducted. Among the patients suspected bacterial infection or fulfilled the criteria of systemic inflammatory response syndrome (SIRS) and patients who underwent blood culture, presepsin, procalcitonin (PCT), and C-reactive protein (CRP) at the same time were included. Receiver operating characteristic (ROC) curve analysis and logistic regression were used to compare performance of three biomarkers. A total of 757 patients were enrolled, including 256 patients (33.8%) with culture-proven bacterial infection and 109 patients (14.4%) with bacteremia. The 28-day mortality rate was 8.6%. ROC curve analysis revealed that the area under the curve (AUC) of PCT was higher than that of presepsin for both culture-proven bacterial infection (0.665 and 0.596, respectively; p = 0.003) and bacteremia (0.791 and 0.685; p < 0.001). In contrast, AUC of PCT for 28-day mortality was slower than presepsin (0.593 and 0.720; p = 0.002). In multivariable logistic regression analysis, PCT showed the highest ORs for culture-proven bacterial infection (OR 2.23, 95% CI 1.55–3.19; p < 0.001) and for bacteremia (OR 5.18, 95% CI 3.13–8.56; p < 0.001), while presepsin showed the highest OR for 28-day mortality (OR 3.31, 95% CI 1.67–6.54; p < 0.001). CRP did not show better performance than PCT or presepsin in any of the analyses. PCT showed the best performance predicting culture-proven bacterial infection and bacteremia, while presepsin would rather be useful as a prognostic marker.

Diagnostic value of mid-regional pro-Adrenomedullin as a biomarker of invasive bacterial infection in children: a systematic review

Background

Invasive bacterial infections (IBI) in children present a difficult clinical challenge. They are often life-threatening, however in the early stages they can be hard to differentiate from benign viral infections. This leaves clinicians with the risk of missing a serious IBI diagnosis or inappropriately using antimicrobials in a child with a viral infection- contributing to the ongoing development of increased antimicrobial resistance. Hence, biomarkers which could aid in early detection of IBI and differentiation from viral infections are desirable. Mid-Regional pro-Adrenomedullin (MR-proADM) is a biomarker which has been associated with IBI. The aim of this systematic review was to determine its diagnostic accuracy in identifying children with IBI.

Methods

A strategy was devised to search online databases MEDLINE, Embase, Web of Science and Scopus for human clinical trials reporting the accuracy of MR-proADM in children. Against predesigned inclusion and exclusion criteria full texts were selected for inclusion and data extraction. True positives, false positives, true negatives and false negatives were extracted from each included study to fill 2 × 2 tables. Using the Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) tool methodological quality of each study was assessed.

Results

A total of 501 articles were initially identified. After the removal of duplicates and abstract screening 11 texts were fully reviewed and four texts (totaling 1404 patients) were included in the systematic analysis. Only one study was of a high quality and that study accounted for the vast majority of patients. A single study reported the diagnostic accuracy of MR-proADM for invasive bacterial infection reporting an Area under the Curve of 0.69. The paucity of available studies made meta-analysis and studies of heterogeneity impossible.

Conclusion

There is a paucity of research regarding the diagnostic accuracy of MR-proADM in the diagnosis of invasive bacterial infections in children. Initial results would suggest that MR-proADM testing alone is poor at identifying IBI in young children. It remains unclear if MR-proADM performs differently in older children or in children with signs and symptoms of IBI.

Trial registration

PROSPERO CRD42018096295.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12887-022-03255-9.

Micro- and nanosensors for detecting blood pathogens and biomarkers at different points of sepsis care

Severe infections can cause a dysregulated response leading to organ dysfunction known as sepsis. Sepsis can be lethal if not identified and treated right away. This requires measuring biomarkers and pathogens rapidly at the different points where sepsis care is provided. Current commercial approaches for sepsis diagnosis are not fast, sensitive, and/or specific enough for meeting this medical challenge. In this article, we review recent advances in the development of diagnostic tools for sepsis management based on micro- and nanostructured materials. We start with a brief introduction to the most popular biomarkers for sepsis diagnosis (lactate, procalcitonin, cytokines, C-reactive protein, and other emerging protein and non-protein biomarkers including miRNAs and cell-based assays) and methods for detecting bacteremia. We then highlight the role of nano- and microstructured materials in developing biosensors for detecting them taking into consideration the particular needs of every point of sepsis care (e.g., ultrafast detection of multiple protein biomarkers for diagnosing in triage, emergency room, ward, and intensive care unit; quantitative detection to de-escalate treatment; ultrasensitive and culture-independent detection of blood pathogens for personalized antimicrobial therapies; robust, portable, and web-connected biomarker tests outside the hospital). We conclude with an overview of the most utilized nano- and microstructured materials used thus far for solving issues related to sepsis diagnosis and point to new challenges for future development.

Biomarkers for sepsis: more than just fever and leukocytosis-a narrative review

A biomarker describes a measurable indicator of a patient's clinical condition that can be measured accurately and reproducibly. Biomarkers offer utility for diagnosis, prognosis, early disease recognition, risk stratification, appropriate treatment (theranostics), and trial enrichment for patients with sepsis or suspected sepsis. In this narrative review, we aim to answer the question, "Do biomarkers in patients with sepsis or septic shock predict mortality, multiple organ dysfunction syndrome (MODS), or organ dysfunction?" We also discuss the role of pro- and anti-inflammatory biomarkers and biomarkers associated with intestinal permeability, endothelial injury, organ dysfunction, blood–brain barrier (BBB) breakdown, brain injury, and short and long-term mortality. For sepsis, a range of biomarkers is identified, including fluid phase pattern recognition molecules (PRMs), complement system, cytokines, chemokines, damage-associated molecular patterns (DAMPs), non-coding RNAs, miRNAs, cell membrane receptors, cell proteins, metabolites, and soluble receptors. We also provide an overview of immune response biomarkers that can help identify or differentiate between systemic inflammatory response syndrome (SIRS), sepsis, septic shock, and sepsis-associated encephalopathy. However, significant work is needed to identify the optimal combinations of biomarkers that can augment diagnosis, treatment, and good patient outcomes.

[Which biomarkers for diagnosis and guidance of anti-infection treatment in sepsis?]

To date no biomarker has been identified bringing together perfect sensitivity and specificity to discriminate between inflammation and infections. Since the 1930s new markers of tissue damage and endothelial damage have been identified but which are incapable of identifying infections in every clinical setting to enable initiation of early antibiotic treatment. In this review the most important classical biomarkers and upcoming new PCR-based approaches are addressed. These markers are highlighted with respect to special clinical settings and to control the success of antibiotic treatment. The issue of discrimination between inflammation and infection is not yet solved. Based on one single biomarker it is impossible to decide whether infection is the reason for the patient's worsening condition but the combination of biomarkers or the integration of new biomarkers may be a meaningful supplement. The measurement of different biomarkers of infection or inflammation is part of the routine in critical care and will be essential in the future.

Sensitivity and specificity of a quick sequential [Sepsis-Related] organ failure assessment sepsis screening tool

AIM

There is limited evidence on the diagnostic accuracy of a quick Sequential [Sepsis-Related] Organ Failure Assessment (qSOFA) sepsis screening (SS) tool in developing nation health settings. The aim of this study was to test the diagnostic accuracy of a qSOFA-based SS tool, and the predictive validity of the qSOFA score in hospital ward patients from Argentina.

METHODS

Prospective observational study. Patients (≥18 years, without sepsis) were recruited within 24-48 hours of admission to a 169-bed tertiary referral private hospital in Buenos Aires. The index test was the qSOFA-based SS tool, and the reference standard sepsis diagnosed at discharge blindly evaluated with reference to the Sepsis-3.

RESULTS

In 1151 patients (median age 69.9 [IQR, 29.0]); 47 (4.1%) had sepsis, 413 (35.9%) had infection and 691 (60.0%) other diagnoses at discharge. The qSOFA-based SS tool (index test) had moderate sensitivity (60%), good specificity (89%), a very low positive (19%) and very high negative (98%) predictive value for sepsis diagnosed at discharge according to the Sepsis-3 criteria (reference standard). For the same outcome, the qSOFA score in isolation had a reasonable predictive validity area under receiver operating characteristics curve 0.77 (95% CI 0.70-0.83) P < 0.001.

CONCLUSION

The qSOFA score could reasonably discriminate patients at risk of developing sepsis; qSOFA-based screening may be valuable where no screening criteria are in place.

Serum C1q Levels Have Prognostic Value for Sepsis and are Related to the Severity of Sepsis and Organ Damage

Objective

To explore the clinical application value of serum complement component C1q levels in sepsis.

Methods

The clinical data and laboratory examination data of 320 research subjects (including 132 cases as sepsis group, 93 cases as nonsepsis group and 95 cases as control group) who were diagnosed and treated in Renmin Hospital of Wuhan University from July 2020 to March 2021 were collected. We compared the levels of each index among the three groups and further analyzed the C1q levels of different severity subgroups and different outcome subgroups of sepsis. Afterwards, we explored the correlation between C1q levels and SOFA score, organ damage indexes and coagulation indexes. Finally, the receiver operating characteristic curve (ROC) was used to analyze the prognostic value of C1q in patients with sepsis.

Results

C1q levels were significantly reduced in the serum of patients with sepsis; the level of C1q in the death group was lower than that in the survival group (127.1 mg/L vs 153.2 mg/L, P < 0.05), and the mortality in the C1q decreased group was higher when compared with C1q normal group; in addition, serum C1q levels were correlated with SOFA score, organ damage indexes and coagulation indexes; C1q had a high area under the curve (AUC) for the prognosis of sepsis, and the combination of other indexes can further improve the prognostic value.

Conclusion

Serum C1q levels have potential clinical value for the condition and prognosis of sepsis.

Diagnostic Performance of Procalcitonin for the Early Identification of Sepsis in Patients with Elevated qSOFA Score at Emergency Admission

Infectious biomarkers such as procalcitonin (PCT) can help overcome the lack of sensitivity of the quick Sequential Organ Failure Assessment (qSOFA) score for early identification of sepsis in emergency departments (EDs) and thus might be beneficial as point-of-care biomarkers in EDs. Our primary aim was to investigate the diagnostic performance of PCT for the early identification of septic patients and patients likely to develop sepsis within 96 h of admission to an ED among a prospectively selected patient population with elevated qSOFA score. In a large multi-centre prospective cohort study, we included all adult patients (n = 742) with a qSOFA score of at least 1 who presented to the ED. PCT levels were measured upon admission. Of the study population 27.3% (n = 202) were diagnosed with sepsis within the first 96 h. The area under the curve for PCT for the identification of septic patients in EDs was 0.86 (95% confidence interval (CI): 0.83–0.89). The resultant sensitivity for PCT at a cut-off of 0.5 µg/L was 63.4% (95% CI: 56.3–70.0). Furthermore, specificity was 89.2% (95% CI: 86.3–91.7), the positive predictive value was 68.8% (95% CI: 62.9–74.2), and the negative predictive value was 86.7% (95% CI: 84.4–88.7). The early measurement of PCT in a patient population with elevated qSOFA score served as an effective tool for the early identification of sepsis in ED patients.

Diagnostic Accuracy and Prognostic Value of Neutrophil-to-Lymphocyte and Platelet-to-Lymphocyte Ratios in Septic Patients outside the Intensive Care Unit

Background and Objectives: The aim of this study was to evaluate the diagnostic accuracy and prognostic value of neutrophil-to-lymphocyte (NLR) and platelet-to-lymphocyte (PLR) ratios and to compare them with other biomarkers and clinical scores of sepsis outside the intensive care unit. Materials and methods: In this retrospective study, 251 patients with sepsis and 126 patients with infection other than sepsis were enrolled. NLR and PLR were calculated as the ratio between absolute values of neutrophils, lymphocytes, and platelets by complete blood counts performed on whole blood by Sysmex XE-9000 (Dasit, Italy) following the manufacturer’s instruction. Results: The best NLR value in diagnosis of sepsis was 7.97 with sensibility, specificity, AUC, PPV, and NPV of 64.26%, 80.16%, 0.74 (p < 0.001), 86.49%, and 53.18%, respectively. The diagnostic role of NLR significantly increases when PLR, C-reactive protein (PCR), procalcitonin (PCT), and mid-regional pro-adrenomedullin (MR-proADM) values, as well as systemic inflammatory re-sponse syndrome (SIRS), sequential organ failure assessment (SOFA), and quick-sequential organ failure assessment (qSOFA) scores, were added to the model. The best value of NLR in predicting 90-day mortality was 9.05 with sensibility, specificity, AUC, PPV, and NPV of 69.57%, 61.44%, 0.66 (p < 0.0001), 28.9%, and 89.9%, respectively. Sensibility, specificity, AUC, PPV, and NPV of NLR increase if PLR, PCR, PCT, MR-proADM, SIRS, qSOFA, and SOFA scores are added to NLR. Conclusions: NLR and PLR represent a widely useful and cheap tool in diagnosis and in predict-ing 90-day mortality in patients with sepsis.

The Diagnostic and Prognostic Value of suPAR in Patients with Sepsis: A Systematic Review and Meta-Analysis

BACKGROUND

Soluble urokinase-type plasminogen activator receptor (suPAR) has the potential to diagnose infectious diseases. Due to the lack of reliable biomarkers and the importance of timely diagnosis for sepsis treatment, we conducted this systematic review and meta-analysis to evaluate the value of suPAR diagnosis and prognosis for sepsis.

METHODS

PubMed, Embase, Web of Science, and Cochrane Library databases were searched for studies, which reported the value of suPAR diagnosis and/or prognosis in patients with sepsis.

RESULTS

A total of 30 studies involving 6,906 patients were included. Sensitivity and specificity of suPAR for diagnosing sepsis were 0.76 [95% confidence interval (CI), 0.63-0.86] and 0.78 (95% CI, 0.72-0.83), respectively. The area under the summary receiver-operating characteristic curve (AUC) was 0.83 (95% CI, 0.80-0.86). Pooled sensitivity and specificity for predicting mortality were 0.74 (95% CI, 0.67-0.80) and 0.70 (95% CI, 0.63-0.76), respectively, with AUC of 0.78 (95% CI, 0.74-0.82). In addition, AUC for differentiating sepsis from systemic inflammatory response syndrome (SIRS) was 0.81 (95% CI, 0.77-0.84), and the sensitivity and specificity were 0.67 (95% CI, 0.58-0.76) and 0.82 (95% CI, 0.73-0.88), respectively.

CONCLUSION

suPAR is a feasible biomarker for timely diagnosis and prognosis of sepsis. Compared with effective value of procalcitonin (PCT) identified by previous meta-analysis, suPAR has similar clinical guiding value, whereas suPAR exhibits higher specificity, which can facilitate the deficiencies of PCT. suPAR also shows a diagnostic value in differentiating sepsis from SIRS. Considering the lack of biomarkers for sepsis and the similar clinical value of suPAR and PCT, suPAR should be considered as a biomarker in clinical practice for sepsis.

The diagnostic accuracy of mid-regional pro-adrenomedullin for sepsis: a systematic review and meta-analysis

BACKGROUND

The incidence and mortality of sepsis are high, and common biomarkers are not perfect. To identify a biomarker with high specificity and sensitivity for sepsis, we evaluated the current literature on the performance of mid-regional pro-adrenomedullin (MR-proADM) in the diagnosis of sepsis.

METHODS

According to appropriate eligibility and exclusion criteria, PubMed, EMBASE, Cochrane Library, China Journal full-text Database, Wanfang Database and Chinese Journal Full Text Database were searched for "Mid-regional proadrenomedullin", "MR-proADM", "Sepsis", "Pyemia", "Pyohemia", "Septicemia" and "Blood poisoning". The publication dates considered for the search were from inception until August 31, 2020. The risk of bias was assessed according to QUADAS-2 criteria.

RESULTS

Eleven studies involving 2038 cases were included. MR-proADM had high sensitivity and specificity in the diagnosis of sepsis, with values of 0.83 [95% CI: (0.79-0.87)] and 0.90 [95% CI: (0.83-0.94)], respectively. The odds ratio of a combined diagnosis was 41.35, and the area under the curve (AUC) was 0.91. The best cut-off value for MR-proADM diagnosis of sepsis is 1-1.5 nmol/L. MRproADM may also have value in distinguishing pathogens and identifying sepsis severity and organ failure.

CONCLUSIONS

MR-proADM is an excellent biomarker for the diagnosis of sepsis with high sensitivity and specificity. The best cut-off value for MR-proADM diagnosis of sepsis is 1-1.5 nmol/L.

Diagnostic value of neutrophil CD64, procalcitonin, and interleukin-6 in sepsis: a meta-analysis

Background

The aim of the study was to conduct a meta-analysis to evaluate the accuracy of neutrophil CD64, procalcitonin (PCT), and interleukin-6 (IL-6) as markers for the diagnosis of sepsis in adult patients.

Methods

Various databases were searched to collect published studies on the diagnosis of sepsis in adult patients using neutrophil CD64, PCT, and IL-6 levels. Utilizing the Stata SE 15.0 software, forest plots and the area under the summary receiver operating characteristic curves were drawn. The pooled sensitivity, specificity, positive likelihood ratio, negative likelihood ratio, diagnostic odds ratio, and area under the curve (AUC) were calculated.

Results

Fifty-four articles were included in the study. The pooled sensitivity, specificity, and AUC of neutrophil CD64 for the diagnosis of sepsis were 0.88 (95% confidence interval [CI], 0.81–0.92), 0.88 (95% CI, 0.83–0.91), and 0.94 (95% CI, 0.91–0.96), respectively. The pooled sensitivity, specificity, and AUC of PCT for the diagnosis of sepsis were 0.82 (95% CI, 0.78–0.85), 0.78 (95% CI, 0.74–0.82), and 0.87 (95% CI, 0.83–0.89), respectively. Subgroup analysis showed that the AUC for PCT diagnosis of intensive care unit (ICU) sepsis was 0.86 (95% CI, 0.83–0.89) and the AUC for PCT diagnosis of non-ICU sepsis was 0.82 (95% CI, 0.78–0.85). The pooled sensitivity, specificity, and AUC of IL-6 for the diagnosis of sepsis were 0.72 (95% CI, 0.65–0.78), 0.70 (95% CI, 0.62–0.76), and 0.77 (95% CI, 0.73–0.80), respectively.

Conclusions

Of the three biomarkers studied, neutrophil CD64 showed the highest diagnostic value for sepsis, followed by PCT, and IL-6. On the other hand, PCT showed a better diagnostic potential for the diagnosis of sepsis in patients with severe conditions compared with that in patients with non-severe conditions.

Mid-regional pro-adrenomedullin as a supplementary tool to clinical parameters in cases of suspicion of infection in the emergency department

INTRODUCTION

Mid-regional proadrenomedullin (MR-proADM), a novel biomarker, has recently gained interest particularly with regards to its potential in assisting clinicians' decision making in patients with suspicion of infection in the emergency department (ED). A group of international experts, with research and experience in MR-proADM applications, produced this review based on their own experience and the currently available literature.

AREAS COVERED

The review provides evidence related to MR-proADM as a triaging tool in avoiding unnecessary admissions to hospital and/or inadequate discharge, and identifying patients most at risk of deterioration. It also covers the use of MR-proADM in the context of COVID-19. Moreover, the authors provide a proposal on how to incorporate MR-proADM into patients' clinical pathways in an ED setting.

EXPERT OPINION

The data we have so far on the application of MR-proADM in the ED is promising. Incorporating it into clinical scoring systems may aid the clinician's decision making and recognizing the 'ill looking well' and the 'well looking ill' sooner. However there are still many gaps in our knowledge especially during the ongoing COVID-19 waves. There is also a need for cost-effectiveness analysis studies especially in the era of increasing cost pressures on health systems globally.

MR-proADM as prognostic factor of outcome in COVID-19 patients

Mid Regional pro-ADM (MR-proADM) is a promising novel biomarker in the evaluation of deteriorating patients and an emergent prognosis factor in patients with sepsis, septic shock and organ failure. It can be induced by bacteria, fungi or viruses. We hypothesized that the assessment of MR-proADM, with or without other inflammatory cytokines, as part of a clinical assessment of COVID-19 patients at hospital admission, may assist in identifying those likely to develop severe disease. A pragmatic retrospective analysis was performed on a complete data set from 111 patients admitted to Udine University Hospital, in northern Italy, from 25th March to 15th May 2020, affected by SARS-CoV-2 pneumonia. Clinical scoring systems (SOFA score, WHO disease severity class, SIMEU clinical phenotype), cytokines (IL-6, IL-1b, IL-8, TNF-α), and MR-proADM were measured. Demographic, clinical and outcome data were collected for analysis. At multivariate analysis, high MR-proADM levels were significantly associated with negative outcome (death or orotracheal intubation, IOT), with an odds ratio of 4.284 [1.893–11.413], together with increased neutrophil count (OR = 1.029 [1.011–1.049]) and WHO disease severity class (OR = 7.632 [5.871–19.496]). AUROC analysis showed a good discriminative performance of MR-proADM (AUROC: 0.849 [95% Cl 0.771–0.730]; p < 0.0001). The optimal value of MR-proADM to discriminate combined event of death or IOT is 0.895 nmol/l, with a sensitivity of 0.857 [95% Cl 0.728–0.987] and a specificity of 0.687 [95% Cl 0.587–0.787]. This study shows an association between MR-proADM levels and the severity of COVID-19. The assessment of MR-proADM combined with clinical scoring systems could be of great value in triaging, evaluating possible escalation of therapies, and admission avoidance or inclusion into trials. Larger prospective and controlled studies are needed to confirm these findings.

High value of mid-regional proadrenomedullin in COVID-19: A marker of widespread endothelial damage, disease severity, and mortality

The widespread endothelial damage due to severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) may lead to a disruption of the adrenomedullin (ADM) system responsible for vascular leakage, increased inflammatory status, and microvascular alteration with multi‐organs dysfunction. The aim of this study was to evaluate the role of mid‐regional proadrenomedullin (MR‐proADM) as a marker of SARS‐CoV2 related widespread endothelial damage, clinically identified by organs damage, disease severity and mortality. Patients with SARS‐CoV‐2 infection has been prospectively enrolled and demographic characteristic, clinical and laboratory data has been evaluated. In the overall population, 58% developed acute respiratory distress syndrome (ARDS), 23.3% of patients died, 6.5% acute cardiac injury, 1.4% of patients developed acute ischemic stroke, 21.2% acute kidney injury, 11.8% acute liver damage, and 5.4% septic shock. The best MR‐proADM cut‐off values for ARDS development and mortality prediction were 3.04 and 2 nmol/L, respectively. Patients presenting with MR‐proADM values ≥2 nmol/L showed a significantly higher mortality risk. In conclusion, MR‐proADM values ≥2 nmol/L identify those patients with high mortality risk related to a multiorgan dysfunction syndrome. These patients must be carefully evaluated and considered for an intensive therapeutic approach.

Does mid-regional pro-adrenomedullin (MR-proADM) improve the sequential organ failure assessment-score (SOFA score) for mortality-prediction in patients with acute infections? Results of a prospective observational study

OBJECTIVES

Risk stratification in patients with infection is usually based on the Sequential Organ Failure Assessment-Score (SOFA score). Our aim was to investigate whether the vasoactive peptide mid-regional pro-adrenomedullin (MR-proADM) improves the predictive value of the SOFA score for 30-day mortality in patients with acute infection presenting to the emergency department (ED).

METHODS

This secondary analysis of the prospective observational TRIAGE study included 657 patients with infection. The SOFA score, MR-proADM, and traditional inflammation markers were all measured at time of admission. Associations of admission parameters and 30-day mortality were investigated by measures of logistic regression, discrimination analyses, net reclassification index (NRI), and integrated discrimination index (IDI).

RESULTS

MR-proADM values were higher in non-survivors compared with survivors (4.5±3.5 nmol/L vs. 1.7 ± 1.8 nmol/L) with an adjusted odds ratio of 26.6 (95% CI 3.92 to 180.61, p=0.001) per 1 nmol/L increase in admission MR-proADM levels and an area under the receiver operator curve (AUC) of 0.86. While the SOFA score alone revealed an AUC of 0.81, adding MR-proADM further improved discrimination (AUC 0.87) and classification within predefined risk categories (NRI 0.075, p-value <0.05). An admission MR-proADM threshold of 1.75 nmol/L provided the best prognostic accuracy for 30-day mortality; with a sensitivity of 81% and a specificity of 75%, and a negative predictive value of 98%.

CONCLUSIONS

MR-proADM improved the mortality risk stratification in patients with infection presenting to the ED beyond SOFA score alone and may further improve initial therapeutic site-of-care decisions.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01768494. Registered January 15, 2013.

Usefulness of ischemia-modified albumin in the diagnosis of sepsis/septic shock in the emergency department

Objective

No studies have evaluated the diagnostic value of ischemia-modified albumin (IMA) for the early detection of sepsis/septic shock in patients presenting to the emergency department (ED). We aimed to assess the usefulness of IMA in diagnosing sepsis/septic shock in the ED.

Methods

This retrospective, observational study analyzed IMA, lactate, high sensitivity C-reactive protein, and procalcitonin levels measured within 1 hour of ED arrival. Patients with suspected infection meeting at least two systemic inflammatory response syndrome criteria were included and classified into the infection, sepsis, and septic shock groups using Sepsis-3 definitions. Areas under the receiver operating characteristic curves (AUCs) with 95% confidence intervals (CIs) and multivariate logistic regression were used to determine diagnostic performance.

Results

This study included 300 adult patients. The AUC (95% CI) of IMA levels (cut-off ≥85.5 U/mL vs. ≥87.5 U/mL) was higher for the diagnosis of sepsis than for that of septic shock (0.729 [0.667–0.791] vs. 0.681 [0.613–0.824]) and was higher than the AUC of procalcitonin levels (cut-off ≥1.58 ng/mL, 0.678 [0.613–0.742]) for the diagnosis of sepsis. When IMA and lactate levels were combined, the AUCs were 0.815 (0.762–0.867) and 0.806 (0.754–0.858) for the diagnosis of sepsis and septic shock, respectively. IMA levels independently predicted sepsis (odds ratio, 1.05; 95% CI, 1.00–1.09; P=0.029) and septic shock (odds ratio, 1.07; 95% CI, 1.02–1.11; P=0.002).

Conclusion

Our findings indicate that IMA levels are a useful biomarker for diagnosing sepsis/ septic shock early, and their combination with lactate levels can enhance the predictive power for early diagnosis of sepsis/septic shock in the ED.

Best diagnostic accuracy of sepsis combining SIRS criteria or qSOFA score with Procalcitonin and Mid-Regional pro-Adrenomedullin outside ICU

Early diagnosis and treatment significantly reduce sepsis mortality. Currently, no gold standard has been yet established to diagnose sepsis outside the ICU. The aim of the study was to evaluate the diagnostic accuracy of sepsis defined by SIRS Criteria of 1991, Second Consensus Conference Criteria of 2001, modified Second Consensus Conference Criteria of 2001 (obtaining SIRS Criteria and SOFA score), Third Consensus Conference of 2016, in addition to the dosage of Procalcitonin (PCT) and MR-pro-Adrenomedullin (MR-proADM). In this prospective study, 209 consecutive patients with clinical diagnosis of sepsis were enrolled (May 2014-June 2018) outside intensive care unit (ICU) setting. A diagnostic protocol could include SIRS criteria or qSOFA score evaluation, rapid testing of PCT and MR-proADM, and SOFA score calculation for organ failure definition. Using this approach outside the ICU, a rapid diagnostic and prognostic evaluation could be achieved, also in the case of negative SIRS, qSOFA or SOFA scores with high post-test probability to reduce mortality and improve outcomes.

The value of biomarker-guided antibiotic therapy

INTRODUCTION

There is an increasing interest to individualize patient management and decisions regarding antibiotic treatment. Biomarkers may provide relevant information for this purpose.

AREAS COVERED

Despite a growing number of clinical trials investigating several biomarkers, there remain open questions regarding the best type of biomarker, timing or frequency of testing, and optimal cutoffs among others. The most promising results in regard to diagnosis of bacterial infection and therapy monitoring are found for procalcitonin (PCT), although some recent trials were not able to validate the promising earlier findings. Furthermore, less specific markers like C-reactive protein (CRP) and new prognostic biomarkers such as proadrenomedullin (MR-proADM) may improve the prognostic assessment of patients and proteomics may help shorten time to microbiological results. The aim of this review is to summarize the current concept of biomarker-guided management and provide an outlook of promising ongoing investigations.

EXPERT OPINION

'Antibiotic stewardship' is complex and needs more than just the measurement of one single biomarker. However, when integrated into the context of a thorough clinical examination, standard blood parameters and a well done risk stratification by clinical scores such as the SOFA-score, biomarkers have great potential to improve the diagnostic and prognostic assessment of patients.

How biomarkers can improve pneumonia diagnosis and prognosis: procalcitonin and mid-regional-pro-adrenomedullin

Aim: The diagnostic and prognostic role of procalcitonin (PCT) and mid-regional-pro-adrenomedullin (MR-proADM) were investigated in patients with pneumonia. Material & methods: A total of 168 and 77 patients with pneumonia enrolled in two different hospital settings, an internal medicine unit and an emergency unit were included in the study. PCT and MR-proADM plasma concentrations and pneumonia severity index score were measured. Median values were compared by Mann–Whitney’s test. Receiver operating characteristic analysis and rank correlation were used to define the diagnostic and prognostic accuracy. Results: PCT confirmed the diagnostic role at values 0.08–0.10 ng/ml and MR-proADM the prognostic role for severe pneumonia. Significant correlation (p < 0.0001) between MR-proADM and pneumonia severity index score indicated expression of pneumonia severity. Conclusion: This combination of biomarkers presents a high positive predictive value in pneumonia diagnosis and prognosis.

An Update on Sepsis Biomarkers

Sepsis is a dysregulated systemic reaction to a common infection, that can cause life-threatening organ dysfunction. Over the last decade, the mortality rate of patients with sepsis has decreased as long as patients are treated according to the recommendations of the Surviving Sepsis Campaign, but is still unacceptably high. Patients at risk of sepsis should therefore be identified prior to the onset of organ dysfunction and this requires a rapid diagnosis and a prompt initiation of treatment. Unfortunately, there is no gold standard for the diagnosis of sepsis and traditional standard culture methods are time-consuming. Recently, in order to overcome these limitations, biomarkers which could help in predicting the diagnosis and prognosis of sepsis, as well as being useful for monitoring the response to treatments, have been identified. In addition, recent advances have led to the development of newly identified classes of biomarkers such as microRNAs, long-non-coding RNAs, and the human microbiome. This review focuses on the latest information on biomarkers that can be used to predict the diagnosis and prognosis of sepsis.

Added value of inflammatory markers to vital signs to predict mortality in patients suspected of severe infection

OBJECTIVE

To evaluate the added value of inflammatory markers to vital signs to predict mortality in patients suspected of severe infection.

METHODS

This study was conducted at an acute care hospital (471-bed capacity). Consecutive adult patients suspected of severe infection who presented to either ambulatory care or the emergency department from April 2015 to March 2017 were retrospectively evaluated. A prognostic model for predicting 30-day in-hospital mortality based on previously established vital signs (systolic blood pressure, respiratory rate, and mental status) was compared with an extended model that also included four inflammatory markers (C-reactive protein, neutrophil-lymphocyte ratio, mean platelet volume, and red cell distribution width). Measures of interest were model fit, discrimination, and the net percentage of correctly reclassified individuals at the pre-specified threshold of 10% risk.

RESULTS

Of the 1015 patients included, 66 (6.5%) died. The extended model including inflammatory markers performed significantly better than the vital sign model (likelihood ratio test: p < 0.001), and the c-index increased from 0.69 (range 0.67-0.70) to 0.76 (range 0.75-0.77) (p = 0.01). All included markers except C-reactive protein showed significant contribution to the model improvement. Among those who died, 9.1% (95% CI -2.8-21.8) were correctly reclassified by the extended model at the 10% threshold.

CONCLUSIONS

The inflammatory markers except C-reactive protein showed added predictive value to vital signs. Future studies should focus on developing and validating prediction models for use in individualized predictions including both vital signs and the significant markers.

Biomarkers and clinical scores to identify patient populations at risk of delayed antibiotic administration or intensive care admission

BACKGROUND

The performance of blood biomarkers (mid-regional proadrenomedullin (MR-proADM), procalcitonin (PCT), C-reactive protein (CRP), and lactate) and clinical scores (Sequential Organ Failure Assessment (SOFA), National Early Warning Score (NEWS), and quick SOFA) was compared to identify patient populations at risk of delayed treatment initiation and disease progression after presenting to the emergency department (ED) with a suspected infection.

METHODS

A prospective observational study across three EDs. Biomarker and clinical score values were calculated upon presentation and 72 h, and logistic and Cox regression used to assess the strength of association. Primary outcomes comprised of 28-day mortality prediction and delayed antibiotic administration or intensive care (ICU) admission, whilst secondary outcomes identified subsequent disease progression.

RESULTS

Six hundred eighty-four patients were enrolled with hospitalisation, ICU admission, and infection-related 28-day mortality rates of 72.8%, 3.4%, and 4.4%, respectively. MR-proADM and NEWS had the strongest association with hospitalisation and the requirement for antibiotic administration, whereas MR-proADM alone had the strongest association with ICU admission (OR [95% CI]: 5.8 [3.1 - 10.8]) and mortality (HR [95% CI]: 3.8 [2.2 - 6.5]). Patient subgroups with high MR-proADM concentrations (≥ 1.77 nmol/L) and low NEWS (< 5 points) values had significantly higher rates of ICU admission (8.1% vs 1.6%; p < 0.001), hospital readmission (18.9% vs. 5.9%; p < 0.001), infection-related mortality (13.5% vs. 0.2%; p < 0.001), and disease progression (29.7% vs. 4.9%; p < 0.001) than corresponding patients with low MR-proADM concentrations. ICU admission was delayed by 1.5 [0.25 - 5.0] days in patients with high MR-proADM and low NEWS values compared to corresponding patients with high NEWS values, despite similar 28-day mortality rates (13.5% vs. 16.5%). Antibiotics were withheld in 17.4% of patients with high MR-proADM and low NEWS values, with higher subsequent rates of ICU admission (27.3% vs. 4.8%) and infection-related hospital readmission (54.5% vs. 14.3%) compared to those administered antibiotics during ED treatment.

CONCLUSIONS

Patients with low severity signs of infection but high MR-proADM concentrations had an increased likelihood of subsequent disease progression, delayed antibiotic administration or ICU admission. Appropriate triage decisions and the rapid use of antibiotics in patients with high MR-proADM concentrations may constitute initial steps in escalating or intensifying early treatment strategies.

Usefulness of qSOFA and SIRS scores for detection of incipient sepsis in general ward patients: A prospective cohort study

PURPOSE

To prospectively assess the diagnostic value of quick Sequential Organ Failure Assessment (qSOFA) and systemic inflammatory response syndrome (SIRS) scores for sepsis in ward patients with infections.

MATERIALS AND METHODS

Consecutive patients admitted with infection or developing infection during hospital stay were included. All variables for calculating qSOFA, SIRS, and SOFA scores were collected, and the maximum scores were determined until hospital discharge, death, or day 28, whichever occurred earlier. The primary outcome was sepsis at 28 days. Diagnostic and prognostic values were assessed using the area under the receiver operating characteristic curve (AUROC) with the conventional cutoff value of 2.

RESULTS

Of 409 general ward patients, 146 patients and 371 patients met qSOFA and SIRS criteria, 229 patients developed sepsis. Although qSOFA score had a better overall diagnostic performance of sepsis (AUROC 0.75 vs. 0.69), it had a much lower sensitivity (53% vs. 98%) and higher specificity (87% vs. 18%) than SIRS score. In addition, qSOFA score had a better prognostic value than SIRS score (AUROC 0.86 vs. 0.67).

CONCLUSIONS

Neither SIRS score nor qSOFA score could serve as an ideal screening tool for early identification sepsis, whereas qSOFA score might help to identify patients with higher risk of poor clinical outcome.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT02930070.

Mid-Regional Pro-Adrenomedullin (MR-proADM) as a Biomarker for Sepsis and Septic Shock: Narrative Review

Early identification and diagnosis of sepsis and septic shock is vitally important; despite appropriate management, mortality and morbidity rates remain high. For this reason, many biomarkers and screening systems have been investigated in accordance with the precision medicine concept. A narrative review was conducted to assess the role of mid-regional pro-adrenomedullin (MR-proADM) as a biomarker for sepsis and septic shock. Relevant studies were collected via an electronic PubMed, Web of Science, and The Cochrane Library search. The review focused on both diagnosis and prognosis in patients with sepsis and septic shock and specifically in subpopulations of patients with sepsis and septic shock with burns or malignant tumors. No exclusion criteria regarding age, sex, intensive care unit admission, follow-up duration, or co morbidities were used so as to maximize sensitivity and due to lack of randomized controlled trials, opinion paper and reviews were also included in this review. A total of 22 studies, one opinion paper, and one review paper were investigated. MR-proADM levels were found to be useful in assessing patients’ initial evolution and become even more useful during follow-up with increased area under curve values in the mortality prognosis by exceeding values of 0.8 in the data shown in several studies. These results also improve along with other biomarkers or severity scores and especially correlate with the organ failure degree. The results of this study indicate that MR-proADM is a good biomarker for the diagnosis and prognosis of sepsis and septic shock patients as well as for organ failure. Although several publications have discussed its role as a biomarker for pneumonia, its value as a biomarker for sepsis and septic shock should now be assessed in randomized controlled trials and more collaborative prospective studies with larger patient samples.

Clinical Utility of Rapid Pathogen Identification for Detecting the Causative Organisms in Sepsis: A Single-Center Study in Korea

Purpose

The aim of this pre- and postintervention cohort study was evaluating how effectively rapid pathogen identification with matrix-assisted laser desorption/ionization time-of-flight mass spectrometry (MALDI-TOF MS) detected the causative organisms in sepsis.

Methods

All consecutive adult patients who had bacteremia within 72 h of intensive care unit admission and met ≥2 quick Sequential Organ Failure Assessment criteria at intensive care unit admission were analyzed. The patients whose microorganisms were identified via MALDI-TOF MS between March 2014 and February 2016 formed the postintervention group. The patients whose microorganisms were identified by using conventional methods between March 2011 and February 2013 formed the preintervention group.

Results

The postintervention group (n=58) had a shorter mean time from blood draw to receiving the antimicrobial susceptibility results than the preintervention group (n=40) (90.2 ± 32.1 vs. 108.7 ± 43.1 h; p=0.02). The postintervention group was also more likely to have received active antimicrobial therapy by the time the susceptibility report became available (77% vs. 47%; p=0.005). Its 28-day mortality was also lower (40% vs. 70%; p=0.003). Univariate analysis showed that identification via MALDI-TOF MS (odds ratio, 0.28; 95% confidence interval, 0.12–0.66; p=0.004) and active therapy (odds ratio, 0.38; 95% confidence interval, 0.16–0.95; p=0.04) were associated with lower 28-day mortality.

Conclusion

Rapid microorganism identification via MALDI-TOF MS followed by appropriate antimicrobial therapy may improve the clinical outcomes of patients with sepsis.

Mid regional pro-adrenomedullin for the prediction of organ failure in infection. Results from a single centre study

Biomarkers are widely used to confirm the presence of infection. However, it would be of the greatest importance to predict in advance the occurrence or worsening of organ dysfunction in infected patients allowing timely antibiotic escalation. This study investigates the ability of procalcitonin (PCT) and MR-proADM to predict the transition to sepsis in infected patients. The study was conducted in a neurointensive care unit over a three-month period. We included both patients with and without infection to investigate the specificity of organ dysfunction prediction in infected patients. Daily measurement of PCT and MR-proADM, SOFA, Pitt, and CPIS were performed. To measure the correlation between each biomarker and each severity score, linear mixed-effects models were developed. For each biomarker-score combination we tested the correlation of the score with the biomarker measured one and two days before, the same day, and the day after. Sixty-four critically ill patients, 31 with infection, were enrolled. The statistically significant biomarker-score combinations were PCT-SOFA, MR-proADM-SOFA, MR-proADM-Pitt, and MR-proADM-CPIS. The MR-proADM models predicting Pitt and CPIS variations with 24-hour anticipation showed the best fit. The scores increased by 0.6 ± 0.3 and 0.4 ± 0.2 for each unitary biomarker increase, respectively. The MR-proADM-SOFA combinations were equivalent when the biomarker was measured the day before or the same day (score increases were 1.5 ± 0.4 and 1.9 ± 0.4, respectively). The PCT-SOFA model had the best fit when PCT was measured the same day of the score. There was no difference in the predictive ability of the biomarker in infected and non-infected patients. This was a pivotal study conducted in a single neurointensive centre on a limited number of patients, and as such it does not provide definitive conclusions. PR-proADM predicted occurrence and worsening of organ failure in critically ill patients with and without infection. The combination with infection diagnostic biomarkers such as PCT would allow predicting evolution to sepsis in infected patients.