Poor performance of quick-SOFA (qSOFA) score in predicting severe sepsis and mortality - a prospective study of patients admitted with infection to the emergency department

Differential expression of plasma cytokines in sepsis patients and their clinical implications

BACKGROUND

Sepsis, which is characterized by acute systemic inflammation and is associated with high rates of morbidity and mortality, presents a significant challenge in health care. Some scholars have found that the sequential organ failure assessment (SOFA) and quick SOFA scores are not ideal for predicting severe sepsis and mortality. Microbial culture takes a long time (2-3 d) and provides no information for early diagnosis and treatment. Therefore, new diagnostic methods for sepsis need to be explored.

AIM

To assess cytokine levels in the plasma of sepsis patients and identify potential biomarkers for diagnosing sepsis.

METHODS

Ten sepsis patients admitted to the emergency department within 24 h of onset were enrolled as the observation group, whereas ten noninfected patients served as the control group. Of the 10 noninfected patients, 9 hypertension combined with cerebral infarction, 1 patients with vertiginous syndrome. Plasma Cytokines were measured using the Bio-Plex Pro™ Human Chemokine Panel 40-plex. Differentially expressed cytokines in plasma of sepsis and nonsepsis patients were analyzed using Gene Ontology (GO) functional enrichment and Kyoto Encyclopedia of Genes and Genomes (KEGG) pathway analyses.

RESULTS

Interleukin (IL)-16, granulocyte-macrophage granulocyte-macrophage colony-stimulating factor (GM-CSF), CX3CL1, CXCL9, CXCL16, CCL25, and CCL23 plasma levels were significantly increased in sepsis patients. GO analysis revealed that these cytokines were mainly associated with cellular structures such as intermediates, nuclear plaques, adhesion plaques, lateral plasma membranes, and cell matrix junctions. These genes were involved in various molecular functions, such as cytokine activity, receptor ligand activity, and signal receptor activator activity, contributing to various biological functions, such as leukocyte chemotaxis, migration, and chemotaxis. KEGG analysis indicated involvement in cytokine cytokine receptor interactions, chemokine signaling pathways, virus-protein interactions with cytokines and cytokine receptors, and the tumor necrosis factor signaling pathway.

CONCLUSION

Elevated serum levels of IL-16, GM-CSF, CX3CL1, CXCL9, CXCL16, CCL25, and CCL23 in sepsis patients suggest their potential as diagnostic biomarkers for sepsis.

Importance of qSOFA Score in Terms of Prognosis and Mortality in Critical Care Patients

Background

Recent studies have analyzed the qSOFA (quick sequential organ failure assessment) score as a prognostic indicator in many diseases, particularly sepsis. However, the effect of qSOFA score on prognosis and mortality in critical care patients has not been sufficiently analyzed. There is not enough data, especially regarding its use as critical care mortality and prognosis scoring. In this study, we aimed to analyze the effect of qSOFA score on mortality and prognosis in critical care unit (CCU) patients.

Methods

This study was conducted retrospectively using the chart review method. The APACHE II (Acute Physiology and Chronic Health Evaluation II) and SOFA (Sequential Organ Failure Assessment) scores of patients admitted to our CCU were compared with the qSOFA score. In addition, the need for intubation and mechanical ventilation, short- and long term mortality rates, the relationship between blood gas lactate values and qSOFA score were analyzed.

Results

A total of 1816 patients were included in the study. During critical care follow-up, 374 (20.6%) of our patients died, and at the end of 6 months, 796 (43.8%) of our patients died. A statistically significant association was found between in-hospital mortality and qSOFA, SOFA scores and lactate levels (P = 0.001, P = 0.001, P = 0.01 respectively). A statistically significant association was found between 6-month mortality and SOFA score only. (P = 0.001) The SOFA score appeared to be the most successful predictor of mortality. The cut-off for mortality using the ROC curve was ≥ 7 [sensitivity 78.1%; specificity 85.9%; AUC 0.91; 95% confidence interval (CI), 0.89 to 0.92; P = 0.001]. qSOFA scoring also performed well. The cut-off value for mortality using the ROC curve was ≥ 2 (sensitivity 42.5%; specificity 93.9%; AUC 0.83;95% CI, 0.80-0.85; P = 0.001).

Conclusion

We believe that the qSOFA score can be used as a marker for in-hospital mortality and prognosis in critical care patients. Especially in cases where the qSOFA score is ≥ 2, it provides valuable information regarding mortality and prognosis.

Association between prehospital ROX index with 30-day mortality among septic shock

PURPOSE

Respiratory dysfunction is one of the most frequent symptoms observed during sepsis reflecting hypoxemia and/or acidosis that may be assessed by the ROX index (ratio of oxygen saturation by pulse oximetry/fraction of inspired oxygen to respiratory rate). This study aimed to describe the relationship between the prehospital ROX index and 30-day mortality rate among septic shock patients cared for in the prehospital setting by a mobile intensive care unit (MICU).

METHODS

From May 2016 to December 2021, 530 septic shock patients cared for by a prehospital MICU were retrospectively analysed. Initial ROX index value was calculated at the first contact with MICU. A Cox regression analysis after propensity score matching was performed to assess the relationship between 30-day mortality rate and a ROX index ≤ 10.

RESULTS

Pulmonary, digestive and urinary sepsis were suspected among 43%, 25% and 17% patients, respectively. The 30-day overall mortality reached 31%. Cox regression analysis showed a significant association between 30-day mortality and a ROX index ≤ 10: adjusted hazard ratio of 1.54 [1.08-2.31], p < 0.05.

CONCLUSIONS

During the prehospital stage of septic shock patients cared for by a MICU, ROX index is significantly associated with 30-day mortality. A prehospital ROX ≤ 10 value is associated with a 1.5-fold 30-day mortality rate increase. Prospective studies are needed to confirm the ability of prehospital ROX to predict sepsis outcome since the prehospital setting.

Risk Factors for Systemic Inflammatory Response Syndrome After Percutaneous Transhepatic Cholangioscopic Lithotripsy

Background

There is a lack of validated predictive models for the occurrence of systemic inflammatory response syndrome (SIRS) after percutaneous transhepatic cholangioscopic lithotripsy (PTCSL) for the treatment of hepatolithiasis. This is the first study to estimate the incidence of SIRS after PTCSL.

Methods

A retrospective analysis of 284 PTCSL sessions for the treatment of hepatolithiasis at our institution between January 2019 and January 2023 was performed. The development of SIRS after PTCSL was the primary study endpoint. Independent risk factors for SIRS after PTCSL were identified using univariate and multivariate logistic regression analyses. A nomogram prediction model was constructed using these independent risk factors, and the predictive value was assessed using receiver operating characteristic (ROC) curves.

Results

The incidence of SIRS after PTCSL was 20.77%. According to multivariate analysis, the number of PTCSL sessions (odds ratio [OR]=0.399, 95% confidence interval [CI]=0.202-0.786, p=0.008), stone location (OR=2.194, 95% CI=1.107-4.347, p=0.024), intraoperative use of norepinephrine (OR=0.301, 95% CI=0.131-0.689, p=0.004), intraoperative puncture (OR=3.476, 95% CI=1.749-6.906, P<0.001), preoperative gamma-glutamyltransferase (OR=1.002, 95% CI=1.001-1.004, p=0.009), and preoperative total lymphocyte count (OR=1.820, 95% CI=1.110-2.985, p=0.018) were found to be independent risk factors for the development of SIRS after PTCSL. These six independent risk factors were used to construct a nomogram prediction model, which showed satisfactory accuracy with an area under the ROC curve of 0.776 (95% CI: 0.702-0.850).

Conclusion

The number of PTCSL sessions, stone location, intraoperative use of norepinephrine, intraoperative puncture, preoperative gamma-glutamyltransferase, and preoperative total lymphocyte count may predict the occurrence of SIRS after PTCSL. This prediction model may help clinicians identify high-risk patients in advance.

Risk Factors and Scoring Systems to Predict the Mortality Risk of Afebrile Adult Patients with Monomicrobial Gram-Negative Bacteremia: A 10-Year Observational Study in the Emergency Department

BACKGROUND

The mortality rate of afebrile bacteremia has been reported to be as high as 45%. This investigation focused on the risk factors and predictive performance of scoring systems for the clinical outcomes of afebrile patients with monomicrobial gram-negative bacteria (GNB) in the emergency department (ED).

METHODS

We conducted a retrospective analysis of afebrile adult ED patients with monomicrobial GNB bacteremia from January 2012 to December 2021. We dissected the demographics, clinical pictures, and laboratory investigations. We applied five scoring systems and three revised systems to predict the clinical outcomes.

RESULTS

There were 600 patients included (358 males and 242 females), with a mean age of 69.6 ± 15.4 years. The overall mortality rate was 50.17%, reaching 68.52% (74/108) in cirrhotic patients. Escherichia coli was the leading pathogen (42.83%). The non-survivors had higher scores of the original MEDS (p < 0.001), NEWS (p < 0.001), MEWS (p < 0.001), qSOFA (p < 0.001), and REMS (p = 0.030). In univariate logistic regression analyses, several risk factors had a higher odds ratio (OR) for mortality, including liver cirrhosis (OR 2.541, p < 0.001), malignancy (OR 2.259, p < 0.001), septic shock (OR 2.077, p = 0.002), and male gender (OR 0.535, p < 0.001). The MEDS demonstrated that the best predictive power with the maximum area under the curve (AUC) was measured at 0.773 at the cut-off point of 11. The AUCs of the original NEWS, MEWS, qSOFA, and REMS were 0.663, 0.584, 0.572, and 0.553, respectively. We revised the original MEDS, NEWS, and qSOFA by adding red cell distribution width, albumin, and lactate scores and found a better predictive power of the AUC of 0.797, 0.719, and 0.694 on the revised MEDS ≥11, revised qSOFA ≥ 3, and revised NEWS ≥ 6, respectively.

CONCLUSIONS

The original MEDS, revised MEDS, revised qSOFA, and revised NEWS were valuable tools for predicting the mortality risk in afebrile patients with monomicrobial GNB bacteremia. We suggested that clinicians should explore patients with the risk factors mentioned above for possible severe infection, even in the absence of fever and initiate hemodynamic support and early adequate antibiotic therapy in patients with higher scores of the original MEDS (≥11), revised MEDS (≥11), revised NEWS (≥6), and revised qSOFA (≥3).

The prehospital NEW score to assess septic shock in-hospital, 30-day and 90-day mortality

BACKGROUND

The early identification of sepsis presenting a high risk of deterioration is a daily challenge to optimise patient pathway. This is all the most crucial in the prehospital setting to optimize triage and admission into the appropriate unit: emergency department (ED) or intensive care unit (ICU). We report the association between the prehospital National Early Warning Score 2 (NEWS-2) and in-hospital, 30 and 90-day mortality of SS patients cared for in the pre-hospital setting by a mobile ICU (MICU).

METHODS

Septic shock (SS) patients cared for by a MICU between 2016, April 6th and 2021 December 31st were included in this retrospective cohort study. The NEWS-2 is based on 6 physiological variables (blood pressure, heart rate, respiratory rate, temperature, oxygen saturation prior oxygen supplementation, and level of consciousness) and ranges from 0 to 20. The Inverse Probability Treatment Weighting (IPTW) propensity method was applied to assess the association with in-hospital, 30 and 90-day mortality. A NEWS-2 ≥ 7 threshold was chosen for increased clinical deterioration risk definition and usefulness in clinical practice based on previous reports.

RESULTS

Data from 530 SS patients requiring MICU intervention in the pre-hospital setting were analysed. The mean age was 69 ± 15 years and presumed origin of sepsis was pulmonary (43%), digestive (25%) or urinary (17%) infection. In-hospital mortality rate was 33%, 30 and 90-day mortality were respectively 31% and 35%. A prehospital NEWS-2 ≥ 7 is associated with an increase in-hospital, 30 and 90-day mortality with respective RRa = 2.34 [1.39-3.95], 2.08 [1.33-3.25] and 2.22 [1.38-3.59]. Calibration statistic values for in-hospital mortality, 30-day and 90-day mortality were 0.54; 0.55 and 0.53 respectively.

CONCLUSION

A prehospital NEWS-2 ≥ 7 is associated with an increase in in-hospital, 30 and 90-day mortality of septic shock patients cared for by a MICU in the prehospital setting. Prospective studies are needed to confirm the usefulness of NEWS-2 to improve the prehospital triage and orientation to the adequate facility of sepsis.

RELATIONSHIP BETWEEN SHOCK INDEX, MODIFIED SHOCK INDEX, AND AGE SHOCK INDEX AND 28-DAY MORTALITY AMONG PATIENTS WITH PREHOSPITAL SEPTIC SHOCK

BACKGROUND

A relative hypovolemia occurs during septic shock (SS); the early phase is clinically reflected by tachycardia and low blood pressure. In the prehospital setting, simple objective tools to assess hypovolemia severity are needed to optimize triaging.

OBJECTIVE

The aim of this study was to evaluate the relationship between shock index (SI), diastolic SI (DSI), modified SI (MSI), and age SI (ASI) and 28-day mortality of patients with SS initially cared for in a prehospital setting of a mobile intensive care unit (MICU).

METHODS

From April 6, 2016 through December 31, 2021, 530 patients with SS cared for at a prehospital MICU were analyzed retrospectively. Initial SI, MSI, DSI, and ASI values, that is, first measurement after MICU arrival to the scene were calculated. A propensity score analysis with inverse probability of treatment weighting (IPTW) method was used to assess the relationship between SI, DSI, MSI, and ASI and 28-day mortality.

RESULTS

SS resulted mainly from pulmonary, digestive, and urinary infections in 44%, 25%, and 17% of patients. The 28-day overall mortality was 31%. IPTW propensity score analysis indicated a significant relationship between 28-day mortality and SI (adjusted odds ratio [aOR] 1.13; 95% CI 1.01-1.26; p = 0.04), DSI (aOR 1.16; 95% CI 1.06-1.34; p = 0.03), MSI (aOR 1.03; 95% CI 1.01-1.17; p = 0.03), and ASI (aOR 3.62; 95% CI 2.63-5.38; p < 10-6).

CONCLUSIONS

SI, DSI, MSI, and ASI were significantly associated with 28-day mortality among patients with SS cared for at a prehospital MICU. Further studies are needed to confirm the usefulness of SI and SI derivates for prehospital SS optimal triaging.

Nurses' and Physicians' Experiences After Implementation of a Quality Improvement Project to Improve Sepsis Awareness in Hospitals

Purpose

Previous research has explored nurses´ experience with the implementation of early detection alert systems, and nurses and physicians' perceptions of sepsis management and use of sepsis triage. As one of the first, this study aims to investigate the perceived usefulness of an interdisciplinary quality improvement project including standardized sepsis patient pathway to improve the early identification and treatment of sepsis patients.

Participants and Methods

This study was a qualitative study that employed semi-structured interviews with thirteen ward nurses and five ward physicians recruited by convenience and respondent-driven sampling, respectively. The interviews explored the perceived usefulness of mutual training in sepsis care in medical hospital wards. We applied Systematic Text Condensation to analyze the experiences and knowledge of professional identification and cooperation in early identification of sepsis patients.

Results

The results revealed three main themes: Awareness of sepsis, collaboration between nurses and physicians, and clinical assessment and judgement. The findings highlighted the positive impact of the project in terms of raising awareness, improving communication, and enhancing the ability to detect and treat sepsis. The study also identified the importance of repetition and reminders to maintain awareness, the need for ongoing training for new healthcare professionals, and the challenges of collaboration and decision-making processes.

Conclusion

The sepsis intervention seemed successful in improving awareness of sepsis and enhancing interprofessional collaboration between nurses and physicians. Health professionals continued to rely on their clinical judgment but increased the use of objective measurements and communication of vital signs. Continuous repetition and education for new colleagues were identified as important factors for the sustainability of the intervention. Overall, the study highlights the importance of standardized protocols and training for early detection and management of sepsis in healthcare settings.

Predictors of In-Hospital Mortality in Older Inpatients with Suspected Infection

OBJECTIVES

To determine the rate and predictors of death in older individuals with suspected infection at any time during hospital stay in a geriatric acute ward and the prognostic ability of different tools [quick Sequential (Sepsis-related) Organ Failure Assessment (qSOFA), Modified and National Early Warning Scores (MEWS) and (NEWS)] in such population.

DESIGN

Prospective observational single-center cohort study.

SETTING AND PARTICIPANTS

Among patients admitted to an acute geriatric unit of an Italian University Hospital with at least 1 sepsis risk factor, all subjects with suspected infection at admission or during hospital stay (defined as antibiotic prescription and associated culture test) were considered.

METHODS

A geriatric assessment including comorbidity and social, functional, and cognitive status was performed for each patient. Clinical parameters were evaluated at least twice daily throughout hospital stay; qSOFA, MEWS, and NEWS were derived, with positive cutoffs set at ≥2, ≥5, and ≥7, respectively.

RESULTS

Among 305 older inpatients (median age 86.0 years, 49.2% female), 21% died during hospital stay. Sepsis was diagnosed in 31.8% of the overall sample and in 64.1% of deceased patients. Deceased patients showed a significantly higher prevalence of prior institutionalization, functional dependence, cognitive impairment, and multimorbidity. The prognostic accuracy of the qSOFA score at infection onset was only fair (area under the receiver operating characteristic curve 0.72; 95% CI, 0.65-0.79, P < .001) and comparable with that of MEWS and NEWS. After multivariable analysis, in-hospital death was positively associated with male sex [odds ratio (OR), 2.11; 95% CI, 1.01-4.44; P = .048] and abnormal white blood cells count (OR, 4.93; 95% CI, 2.36-10.29; P < .001), platelet count (OR, 2.61; 95% CI, 1.10-6.16; P = .029) and serum creatinine (OR, 2.70; 95% CI, 1.30-5.61; P = .008), along with any of the score considered, and negatively associated with autonomy in instrumental activities (OR, 0.78; 95% CI, 0.68-0.90; P < .001).

CONCLUSIONS

Prognosis in older inpatients with infection or sepsis appears to be determined both by the geriatric characteristics and by the severity of the acute event, expressed by recommended tools and blood test results.

Prediction of unfavorable outcomes in community-acquired bacteremia by SIRS, SOFA and qSOFA scores

BACKGROUND

Sepsis diagnostic and prognostic scoring systems have changed over time. It remains uncertain which scoring system is the best predictor of unfavorable outcomes. We aimed to evaluate prediction of community-acquired bacteremia (CAB) outcomes using on-admission systemic inflammatory response syndrome (SIRS), sequential organ failure assessment (SOFA) and quick sequential organ failure assessment (qSOFA).

METHODS

We present a retrospective observational cohort study of consecutive adult patients hospitalized with CAB over ten years. SIRS, qSOFA and SOFA scores calculated on admission were dichotomized as ≥2 or 0-1. Raw and adjusted incidence of a composite unfavorable outcome (death, septic shock, invasive mechanical ventilation, extra-corporeal membrane oxygenation, renal replacement therapy) over 35 days were compared.

RESULTS

Among 1930 patients, 1221 (63.3%) had SIRS, 196 (10.2%) had qSOFA, and 1117 (57.9%) had SOFA≥2. Respective raw and adjusted probabilities of the outcome were similar. Incidence for qSOFA≥2 was high (41.3%) and still considerable for qSOFA 0-1 (5.4%). SOFA≥2 indicated higher risk than SIRS≥2 (14.7% vs. 12.4%), while SOFA 0-1 indicated lower risk than SIRS 0-1 (1.2% vs. 3.1%). This relationship between SOFA and SIRS was also observed in patients with qSOFA 0-1.

CONCLUSIONS

qSOFA≥2 was associated with highest probability of unfavorable outcome, but dichotomized SOFA was more precise at high vs. low-risk distinction. Consecutive use of dichotomized qSOFA and SOFA on admission of adults with CAB enables fast and reliable identification of patients at high (qSOFA≥2, risk ~≥35%), moderate (qSOFA 0-1, SOFA≥2, risk ~10%), and low risk (qSOFA 0-1, SOFA 0-1, risk 1-2%) of subsequent unfavorable events.

Construction and validation of machine learning models for sepsis prediction in patients with acute pancreatitis

BACKGROUND

This study aimed to construct predictive models for the risk of sepsis in patients with Acute pancreatitis (AP) using machine learning methods and compared optimal one with the logistic regression (LR) model and scoring systems.

METHODS

In this retrospective cohort study, data were collected from the Medical Information Mart for Intensive Care III (MIMIC III) database between 2001 and 2012 and the MIMIC IV database between 2008 and 2019. Patients were randomly divided into training and test sets (8:2). The least absolute shrinkage and selection operator (LASSO) regression plus 5-fold cross-validation were used to screen and confirm the predictive factors. Based on the selected predictive factors, 6 machine learning models were constructed, including support vector machine (SVM), K-nearest neighbour (KNN), multi-layer perceptron (MLP), LR, gradient boosting decision tree (GBDT) and adaptive enhancement algorithm (AdaBoost). The models and scoring systems were evaluated and compared using sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), accuracy, and the area under the curve (AUC).

RESULTS

A total of 1, 672 patients were eligible for participation. In the training set, 261 AP patients (19.51%) were diagnosed with sepsis. The predictive factors for the risk of sepsis in AP patients included age, insurance, vasopressors, mechanical ventilation, Glasgow Coma Scale (GCS), heart rate, respiratory rate, temperature, SpO2, platelet, red blood cell distribution width (RDW), International Normalized Ratio (INR), and blood urea nitrogen (BUN). The AUC of the GBDT model for sepsis prediction in the AP patients in the testing set was 0.985. The GBDT model showed better performance in sepsis prediction than the LR, systemic inflammatory response syndrome (SIRS) score, bedside index for severity in acute pancreatitis (BISAP) score, sequential organ failure assessment (SOFA) score, quick-SOFA (qSOFA), and simplified acute physiology score II (SAPS II).

CONCLUSION

The present findings suggest that compared to the classical LR model and SOFA, qSOFA, SAPS II, SIRS, and BISAP scores, the machine learning model-GBDT model had a better performance in predicting sepsis in the AP patients, which is a useful tool for early identification of high-risk patients and timely clinical interventions.

Prehospital pulse pressure and mortality of septic shock patients cared for by a mobile intensive care unit

BACKGROUND

Septic shock medical treatment relies on a bundle of care including antibiotic therapy and hemodynamic optimisation. Hemodynamic optimisation consists of fluid expansion and norepinephrine administration aiming to optimise cardiac output to reach a mean arterial pressure of 65mmHg. In the prehospital setting, direct cardiac output assessment is difficult because of the lack of invasive and non-invasive devices. This study aims to assess the relationship between 30-day mortality and (i) initial pulse pressure (iPP) as (ii) pulse pressure variation (dPP) during the prehospital stage among patients cared for SS by a prehospital mobile intensive care unit (MICU).

METHODS

From May 09th, 2016 to December 02nd, 2021, septic shock patients requiring MICU intervention were retrospectively analysed. iPP was calculated as the difference between systolic blood pressure (SBP) and diastolic blood pressure (DBP) at the first contact between the patient and the MICU team prior to any treatment and, dPP as the difference between the final PP (the difference between SBP and DBP at the end of the prehospital stage) and iPP divided by prehospital duration. To consider cofounders, the propensity score method was used to assess the relationship between (i) iPP < 40mmHg, (ii) positive dPP and 30-day mortality.

RESULTS

Among the 530 patients analysed, pulmonary, digestive, and urinary infections were suspected among 43%, 25% and 17% patients, respectively. The 30-day overall mortality rate reached 31%. Cox regression analysis showed an association between 30-day mortality and (i) iPP < 40mmHg; aHR of 1.61 [1.03-2.51], and (ii) a positive dPP; aHR of 0.56 [0.36-0.88].

CONCLUSION

The current study reports an association between 30-day mortality rate and iPP < 40mmHg and a positive dPP among septic shock patients cared for by a prehospital MICU. A negative dPP could be helpful to identify septic shock with higher risk of poor outcome despite prehospital hemodynamic optimization.

Biomarker-Based Assessment Model for Detecting Sepsis: A Retrospective Cohort Study

The concept of the quick sequential organ failure assessment (qSOFA) simplifies sepsis detection, and the next SOFA should be analyzed subsequently to diagnose sepsis. However, it does not include the concept of suspected infection. Thus, we simply developed a biomarker-based assessment model for detecting sepsis (BADS). We retrospectively reviewed the electronic health records of patients admitted to the intensive care unit (ICU) of a 2000-bed university tertiary referral hospital in South Korea. A total of 989 patients were enrolled, with 77.4% (n = 765) of them having sepsis. The patients were divided into a ratio of 8:2 and assigned to a training and a validation set. We used logistic regression analysis and the Hosmer-Lemeshow test to derive the BADS and assess the model. BADS was developed by analyzing the variables and then assigning weights to the selected variables: mean arterial pressure, shock index, lactate, and procalcitonin. The area under the curve was 0.754, 0.615, 0.763, and 0.668 for BADS, qSOFA, SOFA, and acute physiology and chronic health evaluation (APACHE) II, respectively, showing that BADS is not inferior in sepsis prediction compared with SOFA. BADS could be a simple scoring method to detect sepsis in critically ill patients quickly at the bedside.

Early Management of Severe Biliary Infection in the Era of the Tokyo Guidelines

Sepsis of biliary origin is increasing worldwide and has become one of the leading causes of emergency department admissions. The presence of multi-resistant bacteria (MRB) is increasing, and mortality rates may reach 20%. This review focuses on the changes induced by the Tokyo guidelines and new concepts related to the early treatment of severe biliary disease. If cholecystitis or cholangitis is suspected, ultrasound is the imaging test of choice. Appropriate empirical antibiotic treatment should be initiated promptly, and selection should be performed while bearing in mind the severity and risk factors for MRB. In acute cholecystitis, laparoscopic cholecystectomy is the main therapeutic intervention. In patients not suitable for surgery, percutaneous cholecystostomy is a valid alternative for controlling the infection. Treatment of severe acute cholangitis is based on endoscopic or transhepatic bile duct drainage and antibiotic therapy. Endoscopic ultrasound and other new endoscopic techniques have been added to the arsenal as novel alternatives in high-risk patients. However, biliary infections remain serious conditions that can lead to sepsis and death. The introduction of internationally accepted guidelines, based on clinical presentation, laboratory tests, and imaging, provides a framework for their rapid diagnosis and treatment. Prompt assessment of patient severity, timely initiation of antimicrobials, and early control of the source of infection are essential to reduce morbidity and mortality rates.

SIRS, SOFA, qSOFA, and NEWS in the diagnosis of sepsis and prediction of adverse outcomes: a systematic review and meta-analysis

BACKGROUND

We compared Systemic Inflammatory Response Syndrome (SIRS), Sequential Organ Failure Assessment (SOFA), Quick Sepsis-related Organ Failure Assessment (qSOFA), and National Early Warning Score (NEWS) for sepsis diagnosis and adverse outcomes prediction.

METHODS

Clinical studies that used SIRS, SOFA, qSOFA, and NEWS for sepsis diagnosis and prognosis assessment were included. Data were extracted, and meta-analysis was performed for outcome measures, including sepsis diagnosis, in-hospital mortality, 7/10/14-day mortality, 28/30-day mortality, and ICU admission.

RESULTS

Fifty-seven included studies showed good overall quality. Regarding sepsis prediction, SIRS demonstrated high sensitivity (0.85) but low specificity (0.41), qSOFA showed low sensitivity (0.42) but high specificity (0.98), and NEWS exhibited high sensitivity (0.71) and specificity (0.85). For predicting in-hospital mortality, SOFA demonstrated the highest sensitivity (0.89) and specificity (0.69). In terms of predicting 7/10/14-day mortality, SIRS exhibited high sensitivity (0.87), while qSOFA had high specificity (0.75). For predicting 28/30-day mortality, SOFA showed high sensitivity (0.97) but low specificity (0.14), whereas qSOFA displayed low sensitivity (0.41) but high specificity (0.88).

CONCLUSIONS

NEWS independently demonstrates good diagnostic capability for sepsis, especially in high-income countries. SOFA emerges as the optimal choice for predicting in-hospital mortality and can be employed as a screening tool for 28/30-day mortality in low-income countries.

Development and validation of the UCSS score, a novel method to predict septic shock after PCNL

OBJECTIVE

To develop an objective and easily recognizable model to predict septic shock following percutaneous nephrolithotomy (PCNL).

SUBJECTS AND METHODS

First, we identified differences between 431 patients who underwent PCNL with or without septic shock. These data were used to develop existing models and examine their improvement. Multivariate analysis was applied to identify risk factors of septic shock after PCNL based on the scores allocated to the PCNL postoperative test indicators. Finally, we developed a predictive nomogram using the selected factors and compared its performance with that of the existing nomograms SOFA, qSOFA, and SIRS.

RESULTS

Twelve (2.8%) of the patients met the criteria for postoperative septic shock after PCNL. Baseline data analysis revealed differences in sex, preoperative drainage, urinary culture, and urinary leukocyte between groups. After transforming patient data into measurement-level data, we investigated each index score in these conditions, and found that the incidence of septic shock generally increased with the score. Multivariate analysis and early optimization screening revealed that septic shock factors could be predicted using platelets, leukocytes, bilirubin, and procalcitonin levels. We further compared the prediction accuracy of urinary calculi-associated septic shock (UCSS), SOFA, qSOFA, and SIRS scores using the AUC of the ROC curve. As compared to SIRS [AUC 0.938 (95% CI 0.910-0.959)] and qSOFA [AUC 0.930 (95% CI 0.901-0.952)], UCSS [AUC 0.974 (95% Cl 0.954-0.987)] and SOFA [AUC 0.974 (95% CI 0.954-0.987)] scored better at discriminating septic shock after PCNL. We further compared the ROC curves of UCSS with SOFA (95% CI - 0.800 to 0.0808, P = 0.992), qSOFA (95% CI - 0.0611 to 0.0808, P = 0.409), and SIRS (95% CI - 0.0703 to 0.144, P = 0.502), finding that UCSS was non-inferior to these models.

CONCLUSIONS

UCSS, a new convenient and cost-effective model, can predict septic shock following PCNL and provide more accurate discriminative and corrective capability than existing models by including only objective data. The predictive value of UCSS for septic shock after PCNL was greater than that of qSOFA or SIRS scores.

Performance of point-of-care severity scores to predict prognosis in patients admitted through the emergency department with COVID-19

BACKGROUND

Identifying COVID-19 patients at the highest risk of poor outcomes is critical in emergency department (ED) presentation. Sepsis risk stratification scores can be calculated quickly for COVID-19 patients but have not been evaluated in a large cohort.

OBJECTIVE

To determine whether well-known risk scores can predict poor outcomes among hospitalized COVID-19 patients.

DESIGNS, SETTINGS, AND PARTICIPANTS

A retrospective cohort study of adults presenting with COVID-19 to 156 Hospital Corporation of America (HCA) Healthcare EDs, March 2, 2020, to February 11, 2021.

INTERVENTION

Quick Sequential Organ Failure Assessment (qSOFA), Shock Index, National Early Warning System-2 (NEWS2), and quick COVID-19 Severity Index (qCSI) at presentation.

MAIN OUTCOME AND MEASURES

The primary outcome was in-hospital mortality. Secondary outcomes included intensive care unit (ICU) admission, mechanical ventilation, and vasopressors receipt. Patients scored positive with qSOFA ≥ 2, Shock Index > 0.7, NEWS2 ≥ 5, and qCSI ≥ 4. Test characteristics and area under the receiver operating characteristics curves (AUROCs) were calculated.

RESULTS

We identified 90,376 patients with community-acquired COVID-19 (mean age 64.3 years, 46.8% female). 17.2% of patients died in-hospital, 28.6% went to the ICU, 13.7% received mechanical ventilation, and 13.6% received vasopressors. There were 3.8% qSOFA-positive, 45.1% Shock Index-positive, 49.8% NEWS2-positive, and 37.6% qCSI-positive at ED-triage. NEWS2 exhibited the highest AUROC for in-hospital mortality (0.593, confidence interval [CI]: 0.588-0.597), ICU admission (0.602, CI: 0.599-0.606), mechanical ventilation (0.614, CI: 0.610-0.619), and vasopressor receipt (0.600, CI: 0.595-0.604).

CONCLUSIONS

Sepsis severity scores at presentation have low discriminative power to predict outcomes in COVID-19 patients and are not reliable for clinical use. Severity scores should be developed using features that accurately predict poor outcomes among COVID-19 patients to develop more effective risk-based triage.

The Role of Biomarkers and Scores in Describing Urosepsis

Background and Objectives: Patients with urinary tract obstruction (UTO) and systemic inflammatory response syndrome (SIRS) are at risk of developing urosepsis, whose evolution involves increased morbidity, mortality and cost. The aim of this study is to evaluate the ability of already existing scores and biomarkers to diagnose, describe the clinical status, and predict the evolution of patients with complicated urinary tract infection (UTI) and their risk of progressing to urosepsis. Materials and Methods: We conducted a retrospective study including patients diagnosed with UTI hospitalized in the urology department of” Sfântul Apostol Andrei” County Emergency Clinical Hospital (GCH) in Galati, Romania, from September 2019 to May 2022. The inclusion criteria were: UTI proven by urine culture or diagnosed clinically complicated with UTO, fever or shaking chills, and purulent collections, such as psoas abscess, Fournier Syndrome, renal abscess, and paraurethral abscess, showing SIRS. The exclusion criteria were: patients age < 18 years, pregnancy, history of kidney transplantation, hemodialysis or peritoneal dialysis, and patients with missing data. We used the Sequential (Sepsis-Related) Organ Failure Assessment (SOFA) and qSOFA (quick SOFA) scores, and procalcitonin (PCT) to describe the clinical status of the patients. The Charlson Comorbidity Index (CCI) was used to assesses pre-existing morbidities. The hospitalization days and costs and the days of intensive care were considered. Depending on the diagnosis at admission, we divided the patients into three groups: SIRS, sepsis and septic shock. The fourth group was represented by patients who died during hospitalization. Results: A total of 174 patients with complicated UTIs were enrolled in this study. From this total, 46 were enrolled in the SIRS group, 88 in the urosepsis group, and 40 in the septic shock group. A total of 23 patients died during hospitalization and were enrolled in the deceased group. An upward trend of age along with worsening symptoms was highlighted with an average of 56.86 years in the case of SIRS, 60.37 years in the sepsis group, 69.03 years in the septic shock, and 71.04 years in the case of deceased patients (p < 0.04). A statistically significant association between PCT and complex scores (SOFA, CCI and qSOFA) with the evolution of urosepsis was highlighted. Increased hospitalization costs can be observed in the case of deceased patients and those with septic shock and statistically significantly lower in the case of those with SIRS. The predictability of discriminating urosepsis stages was assessed by using the area under the ROC curve (AUC) and very good specificity and sensitivity was identified in predicting the risk of death for PCT (69.57%, 77.33%), the SOFA (91.33%, 76.82%), qSOFA (91.30%, 74.17%) scores, and CCI (65.22%, 88.74%). The AUC value was best for qSOFA (90.3%). For the SIRS group, the PCT (specificity 91.30%, sensitivity 85.71%) and SOFA (specificity 84.78%, sensitivity 78.74%), qSOFA scores (specificity 84.78%, sensitivity 76, 34%) proved to be relevant in establishing the diagnosis. In the case of the septic shock group, the qSOFA (specificity 92.5%, sensitivity 82.71%) and SOFA (specificity 97.5%, sensitivity 77.44%) as well as PCT (specificity 80%, sensitivity 85.61%) are statistically significant disease-defining variables. An important deficit in the tools needed to classify patients into the sepsis group is obvious. All the variables have an increased specificity but a low sensitivity. This translates into a risk of a false negative diagnosis. Conclusions: Although SOFA and qSOFA scores adequately describe patients with septic shock and they are independent prognostic predictors of mortality, they fail to be accurate in diagnosing sepsis. These scores should not replace the conventional triage protocol. In our study, PCT proved to be a disease-defining marker and an independent prognostic predictor of mortality. Patients with important comorbidities, CCI greater than 10, should be treated more aggressively because of increased mortality.

Development and Validation of the Prediction Model of Sepsis in Patients After Percutaneous Nephrolithotomy and Sepsis Progresses to Septic Shock

Background: To study the predictors of sepsis and the progression of sepsis to septic shock in patients after percutaneous nephrolithotomy (PCNL) and to establish and validate predictive models. Methods: The patients were assigned to either the development cohort or the validation cohort depending on their hospital. In the development cohort, univariate and multivariate logistic regression analyses were used to screen independent risk factors for sepsis after PCNL and sepsis progression to septic shock. Nomogram prediction models were established according to the related independent risk factors. Areas under the receiver operating characteristic curves, calibration plots, and decision curve analysis (DCA) were used to estimate the discrimination, calibration, and clinical usefulness of the prediction models, respectively. The two sets of models were further validated on the validation cohort. Results: In the development cohort, the risk factors for sepsis after PCNL were diabetes, urine nitrite, staghorn calculi, HU value, albumin-globulin ratio, and high-sensitivity C-reactive protein/albumin ratio. The pre- and postoperative white blood cell counts were risk factors for the progression of sepsis to septic shock. The area under the ROC curve value for predicting sepsis risk was 0.891 and that for predicting septic shock risk was 0.981 in the development cohort; in the validation cohort, these values were 0.893 and 0.996, respectively. In the development cohort, the calibration test p values in the sepsis and septic shock cohorts were 0.946 and 0.634, respectively; in the validation cohort, these values were 0.739 and 0.208, respectively. DCA of the model in the sepsis and septic shock cohorts showed threshold probabilities of 10%-90% in the development cohort; in the validation cohort, these values were 10%-90%. Conclusion: The individualized nomogram prediction models can help improve the early identification of patients who are at higher risk of developing sepsis after PCNL and the progression of sepsis to septic shock to avoid further damage.

Screening auf Sepsis in der Notfallmedizin – qSOFA ist uns nicht genug

Hintergrund

Die Sepsis ist eine häufige und lebensbedrohliche Komplikation einer akuten Infektion. In der Notfallmedizin hat sich zum Screening auf Sepsis der Quick Sequential-Organ-Failure-Assessment(qSOFA)-Score etabliert. Bereits mit der Einführung des Scores wurde dessen schwache Sensitivität kritisiert. Nun fordern aktuelle Leitlinien, den qSOFA-Score nicht mehr zum Screening auf Sepsis einzusetzen. Als eine Alternative wird der National Early Warning Score 2 (NEWS2) vorgeschlagen.

Ziel der Arbeit

In einer Subanalyse einer Kohorte von notfallmedizinischen Patient*innen soll die diagnostische Aussagekraft des qSOFA-Scores und des NEWS2 zur Erkennung einer Sepsis verglichen werden. Zusätzlich soll gezeigt werden, inwieweit mithilfe von abweichenden Vitalparametern bereits eine Risikoerhöhung für eine Sepsis ableitbar ist.

Methodik

Mittels AUROC (Area Under Receiver Operating Characteristics) und Odds Ratios wurden die Scores bzw. die Vitalparameter auf ihre Fähigkeit untersucht, septische Patient*innen zu erkennen.

Ergebnisse

Von 312 eingeschlossenen Patient*innen wurde bei 17,9 % eine Sepsis diagnostiziert. Der qSOFA-Score erkannte eine Sepsis mit einer AUROC von 0,77 (NEWS2 0,81). Für qSOFA fand sich eine Sensitivität von 57 % (Spezifität 83 %), für NEWS2 96 % (Spezifität 45 %). Die Analyse der einzelnen Vitalparameter zeigte, dass unter Patient*innen mit einer akuten Infektion eine Vigilanzminderung als deutliches Warnsignal für eine Sepsis zu werten ist.

Diskussion

In der Notfallmedizin sollte qSOFA nicht als alleiniges Tool für das Screening auf Sepsis verwendet werden. Bei Verdacht auf eine akute Infektion sollten grundsätzlich sämtliche Vitalparameter erfasst werden, um das Vorliegen einer akuten Organschädigung und somit einen septischen Krankheitsverlauf frühzeitig zu erkennen.

Graphic abstract

Comparison of the systematic Inflammatory response syndrome and the quick sequential organ failure assessment for prognostic accuracy in detecting sepsis in the emergency department: A systematic review

BACKGROUND

Awareness and prompt recognition of sepsis are essential for nurses working in the emergency department (ED), enabling them to make an initial assessment of patients and then to sort them according to their condition s severity. The aim of this systematic review was to investigate prognostic accuracy in detecting sepsis in the emergency department by comparing the previous sepsis-2 screening tool, the Systemic Inflammatory Response Syndrome (SIRS) and the current sepsis-3 screening tool, the Quick Sequential Organ Failure Assessment (qSOFA).

METHODS

This systematic review used the guideline by Bettany-Saltikov and McSherry and was reported according to the Preferred Reporting Items for Systematic Reviews and meta-Analyses (PRISMA) 2020 checklist. The protocol was registered in PROSPERO. A systematic search was conducted using the CINAHL, EMBASE and MEDLINE databases. Study selection and risk of bias was performed independently by pair of authors.

RESULTS

Five articles were included. Overall, SIRS showed higher sensitivity than qSOFA, while qSOFA showed higher specificity than SIRS. The positive predictive value for qSOFA was superior, while there was a minor deviation in negative predictive value between qSOFA and SIRS.

CONCLUSION

The overall recommendation based on the included studies indicates that qSOFA is the better-suited screening tool for prognostic accuracy in detecting sepsis in the emergency department.

Performance of qSOFA Score as a Screening Tool for Sepsis in the Emergency Department

Introduction

Sepsis is the leading cause of mortality, and various scoring systems have been developed for its early identification and treatment. The objective was to test the ability of quick sequential organ failure assessment (qSOFA) score to identify sepsis and predict sepsis-related mortality in the emergency department (ED).

Methods

We conducted a prospective study from July 2018 to April 2020. Consecutive patients with age ≥18 years who presented to the ED with a clinical suspicion of infection were included. Sensitivity, specificity, positive predictive value (PPV), negative predictive values (NPV), and odds ratio (OR) for sepsis related mortality on day 7 and 28 were measured.

Results

A total of 1200 patients were recruited; of which 48 patients were excluded and 17 patients were lost to follow-up. 54 (45.4%) of 119 patients with positive qSOFA (qSOFA >2) died at 7 days and 76 (63.9%) died at 28 days. A total of 103 (10.1%) of 1016 patients with negative qSOFA (qSOFA score <2) died at 7 days and 207 (20.4%) died at 28 days. Patients with positive qSOFA score were at higher odds of dying at 7 days (OR: 3.9, 95% confidence interval [CI]: 3.1-5.2, P < 0.001) and 28 days (OR: 6.9, 95% CI: 4.6-10.3, P < 0.001). The PPV and NPV with positive qSOFA score to predict 7- and 28-day mortality were 45.4%, 89.9% and 63.9%, 79.6%, respectively.

Conclusion

The qSOFA score can be used as a risk stratification tool in a resource-limited setting to identify infected patients at an increased risk of death.

Monocyte Distribution Width as a predictor of community acquired sepsis in patients prospectively enrolled at the Emergency Department

Background

Monocyte Distribution Width (MDW), a simple cellular marker of innate monocyte activation, can be used for the early recognition of sepsis. We performed an observational prospective monocentric study to assess the predictive role of MDW in detecting sepsis in a sample of consecutive patients presenting at the Emergency Department.

Methods

Prospective observational study using demographic and clinical characteristics, past medical history and other laboratory measurements to predict confirmed sepsis using multivariate logistic regression.

Results

A total of 2724 patients were included in the study, of which 272 (10%) had sepsis or septic shock. After adjusting for known and potential risk factors, logistic regression found the following independent predictors of sepsis: SIRS equal to 1 (OR: 2.32, 1.16–4.89) and 2 or more (OR: 27.8, 14.8–56.4), MDW > 22 (OR: 3.73, 2.46–5.70), smoking (OR: 3.0, 1.22–7.31), end stage renal function (OR: 2.3, 1.25–4.22), neurodegenerative disease (OR: 2.2, 1.31–3.68), Neutrophils ≥ 8.9 × 10³/µL (OR: 2.73, 1.82–4.11), Lymphocytes < 1.3 × 10³/µL (OR: 1.72, 1.17–2.53) and CRP ≥ 19.1 mg/L (OR: 2.57, 1.63–4.08). A risk score derived from predictive models achieved high accuracy by using an optimal threshold (AUC: 95%; 93–97%).

Conclusions

The study suggests that incorporating MDW in the clinical decision process may improve the early identification of sepsis, with minimal additional effort on the standard procedures adopted during emergency care.

Assessing organ-level immunoreactivity in a rat model of sepsis using TSPO PET imaging

There is current need for new approaches to assess/measure organ-level immunoreactivity and ensuing dysfunction in systemic inflammatory response syndrome (SIRS) and sepsis, in order to protect or recover organ function. Using a rat model of systemic sterile inflammatory shock (intravenous LPS administration), we performed PET imaging with a translocator protein (TSPO) tracer, [¹⁸F]DPA-714, as a biomarker for reactive immunoreactive changes in the brain and peripheral organs. In vivo dynamic PET/CT scans showed increased [¹⁸F]DPA-714 binding in the brain, lungs, liver and bone marrow, 4 hours after LPS injection. Post-LPS mean standard uptake values (SUV_mean) at equilibrium were significantly higher in those organs compared to baseline. Changes in spleen [¹⁸F]DPA-714 binding were variable but generally decreased after LPS. SUV_mean values in all organs, except the spleen, positively correlated with several serum cytokines/chemokines. In vitro measures of TSPO expression and immunofluorescent staining validated the imaging results. Noninvasive molecular imaging with [¹⁸F]DPA-714 PET in a rat model of systemic sterile inflammatory shock, along with in vitro measures of TSPO expression, showed brain, liver and lung inflammation, spleen monocytic efflux/lymphocytic activation and suggested increased bone marrow hematopoiesis. TSPO PET imaging can potentially be used to quantify SIRS and sepsis-associated organ-level immunoreactivity and assess the effectiveness of therapeutic and preventative approaches for associated organ failures, in vivo.

Sepsis Team Organizational Model to Decrease Mortality for Intra-Abdominal Infections: Is Antibiotic Stewardship Enough?

Introduction. Sepsis is an overwhelming reaction to infection with significant morbidity, requiring urgent interventions in order to improve outcomes. The 2016 Sepsis-3 guidelines modified the previous definitions of sepsis and septic shock, and proposed some specific diagnostic and therapeutic measures to define the use of fluid resuscitation and antibiotics. However, some open issues still exist. Methods. A literature research was performed on PubMed and Cochrane using the terms "sepsis" AND "intra-abdominal infections" AND ("antibiotic therapy" OR "antibiotic treatment"). The inclusion criteria were management of intra-abdominal infection (IAI) and effects of antibiotic stewardships programs (ASP) on the outcome of the patients. Discussion. Sepsis-3 definitions represent an added value in the understanding of sepsis mechanisms and in the management of the disease. However, some questions are still open, such as the need for an early identification of sepsis. Sepsis management in the context of IAI is particularly challenging and a prompt diagnosis is essential in order to perform a quick treatment (source control and antibiotic treatment). Antibiotic empirical therapy should be based on the kind of infection (community or hospital acquired), local resistances, and patient's characteristic and comorbidities, and should be adjusted or de-escalated as soon as microbiological information is available. Antibiotic Stewardship Programs (ASP) have demonstrated to improve antimicrobial utilization with reduction of infections, emergence of multi-drug resistant bacteria, and costs. Surgeons should not be alone in the management of IAI but ideally inserted in a sepsis team together with anaesthesiologists, medical physicians, pharmacists, and infectious diseases specialists, meeting periodically to reassess the response to the treatment. Conclusion. The cornerstones of sepsis management are accurate diagnosis, early resuscitation, effective source control, and timely initiation of appropriate antimicrobial therapy. Current evidence shows that optimizing antibiotic use across surgical specialities is imperative to improve outcomes. Ideally every hospital and every emergency surgery department should aim to provide a sepsis team in order to manage IAI.

Does lactate enhance the prognostic accuracy of the quick Sequential Organ Failure Assessment for adult patients with sepsis? A systematic review

OBJECTIVES

To investigate whether adding lactate to the quick Sequential (sepsis-related) Organ Failure Assessment (qSOFA) improves the prediction of mortality in adult hospital patients, compared with qSOFA alone.

DESIGN

Systematic review in accordance with Preferred Reporting Items for a Systematic Review and Meta-analysis of Diagnostic Test Accuracy Studies guidelines.

DATA SOURCES

Embase, Medline, PubMed, SCOPUS, Web of Science, CINAHL and Open Grey databases were searched in November 2020.

ELIGIBILITY CRITERIA

Original research studies published after 2016 comparing qSOFA in combination with lactate (LqSOFA) with qSOFA alone in adult patients with sepsis in hospital. The language was restricted to English.

DATA EXTRACTION AND SYNTHESIS

Title and abstract screening, full-text screening, data extraction and quality assessment (using Quality Assessment of Diagnostic Accuracy Studies-2) were conducted independently by two reviewers. Extracted data were collected into tables and diagnostic test accuracy was compared between the two tests.

RESULTS

We identified 1621 studies, of which 11 met our inclusion criteria. Overall, there was a low risk of bias across all studies. The area under the receiver operating characteristic (AUROC) curve for qSOFA was improved by the addition of lactate in 9 of the 10 studies reporting it. Sensitivity was increased in three of seven studies that reported it. Specificity was increased in four of seven studies that reported it. Of the six studies set exclusively within the emergency department, five published AUROCs, all of which reported an increase following the addition of lactate. Sensitivity and specificity results varied throughout the included studies. Due to insufficient data and heterogeneity of studies, a meta-analysis was not performed.

CONCLUSIONS

LqSOFA is an effective tool for identifying mortality risk both in adult inpatients with sepsis and those in the emergency department. LqSOFA increases AUROC over qSOFA alone, particularly within the emergency department. However, further original research is required to provide a stronger base of evidence in lactate measurement timing, as well as prospective trials to strengthen evidence and reduce bias.

PROSPERO REGISTRATION NUMBER

CRD42020207648.

Performance of quick sequential organ failure assessment and modified age disease adjusted qadSOFA for the prediction of outcomes in emergency general surgery patients

BACKGROUND

Sepsis is a highly prevalent condition and is associated with a reported in-hospital mortality rate up to 40% in patients with abdominal sepsis requiring emergency general surgery (EGS). The quick sequential organ failure assessment score (qSOFA) has not been studied for EGS patients.

METHODS

Retrospective cohort study in adult patients undergoing abdominal EGS at a university tertiary care center from 2016 to 2018. The primary outcome was mortality. The effect of clinical variables on outcomes was assessed in univariable and multivariable logistic regression analyses. Based on these results, the qSOFA score was modified. The performance of scores was assessed using receiver operating characteristics.

RESULTS

Five hundred seventy-eight patients undergoing abdominal EGS were included. In-hospital mortality was 4.8% (28/578). Independent predictors for mortality were mesenteric ischemia (odds ratio [OR] 15.9; 95% confidence interval [CI] 5.2-48.6; p < 0.001), gastrointestinal tract perforation (OR 4.9; 95% CI 1.7-14.0; p = 0.003), 65 years or older (OR 4.1; 95% CI 1.5-11.4; p = 0.008), and increasing qSOFA (OR 1.8; 95% CI 1.2-2.8; p = 0.007). The modified qSOFA (qadSOFA) was developed. The area under the receiver operating characteristic curve of the qSOFA and qadSOFA for mortality was 0.715 and 0.859, respectively. Optimal cutoff value was identified as qadSOFA ≥ 3 (Youden Index 64.1%).

CONCLUSION

This is the first study investigating the qSOFA as a predictor for clinical outcomes in EGS. Compared with the qSOFA, the new qadSOFA revealed an excellent predictive power for clinical outcomes. Further validation of qadSOFA is warranted.

LEVEL OF EVIDENCE

Diagnostic test/criteria; Level II.

Heparin-binding protein-enhanced quick SOFA score improves mortality prediction in sepsis patients

Purpose

The Quick Sequential Organ Failure Assessment (qSOFA) score proposed by Sepsis-3 as a sepsis screening tool has shown suboptimal accuracy. Heparin-binding protein (HBP) has been shown to identify early sepsis with high accuracy. Herein, we aim to investigate whether or not HBP improves the model performance of qSOFA.

Methods

We conducted a multicenter prospective observational study of 794 adult patients who presented to the emergency department (ED) with presumed sepsis between 2018 and 2019. For each participant, serum HBP levels were measured and the hospital course was followed. The qSOFA score was used as the comparator. The data was split into a training dataset (n = 556) and a validation dataset (n = 238). The primary endpoint was 30-day all-cause mortality.

Results

Compared with survivors, non-survivors had significantly higher serum HBP levels (median: 71.5 ng/mL vs 209.5 ng/mL, p < 0.001). Serum level of HBP weakly correlated with qSOFA class (r² = 0.240, p < 0.001). Compared with the qSOFA model alone, the addition of admission HBP level to the qSOFA model significantly improved 30-day mortality discrimination (AUC, 0.70 vs. 0.80; P < 0.001), net reclassification improvement [26% (CI, 17–35%); P < 0.001], and integrated discrimination improvement [12% (CI, 9–14%); P < 0.001]. Addition of C-reactive protein (CRP) level or neutrophil-to-lymphocyte ratio (NLR) to qSOFA did not improve its performance. A web-based mortality risk prediction calculator was created to facilitate clinical implementation.

Conclusion

This study confirms the value of combining qSOFA and HBP in predicting sepsis mortality. The web calculator provides a user-friendly tool for clinical implementation. Further validation in different patient populations is needed before widespread application of this prediction model.

Accuracy of Quick Sequential Organ Failure Assessment Score & Systemic Inflammatory Response Syndrome Criteria in Predicting Adverse Outcomes in Emergency Surgical Patients With Suspected Sepsis: A Prospective Observational Study

Purpose: Due to the mixed population enrolled in different studies i.e., medical and surgical cases, conflicting data exists about the accuracy of quick sequential organ failure assessment (qSOFA) and systemic inflammatory response syndrome (SIRS) scores in predicting adverse outcomes in patients with suspected sepsis presenting to the surgical emergency.

Method: A prospective observational study was done in the department of surgery of a tertiary teaching hospital, India from June 2018 to July 2019. Consecutive patients who visited the surgical emergency department with suspected sepsis were included. Patients were followed up until hospital discharge or death.

Results: Of the 410 patients screened, 287 were included in the analysis. The median age was 52 years (interquartile range, 41 to 61years) and 208 (72.8%) were men. Around 56.8% of patients had intra-abdominal pathology, and 43.2% had skin and soft -tissue infection. Sixty-nine (24%) patients died during their hospitalization, 98 (34.1%) patients had organ dysfunction, and 168 (58.5%) patients needed admission to the intensive care unit (ICU). A higher qSOFA score (≥2) was associated with organ dysfunction, ICU admission, and in-hospital mortality. The specificity, positive predictive value and diagnostic accuracy of qSOFA for organ dysfunction (85.7%, 67.8%, 76.3%), ICU admission (92.4%, 89.3%, 64.5%), and in-hospital mortality (81.6%, 52.4%, 77.4%) was higher than SIRS. The area under the receiver operating characteristic curve for qSOFA for these variables was also higher than for SIRS (0.826 vs. 0.524, 0.823 vs. 0.577, and 0.823 vs. 0.555, respectively).

Conclusion: qSOFA is a better model for predicting adverse outcomes and mortality, organ dysfunction, and ICU admission in surgical patients. However, SIRS indicates intervention requirements in a surgical patient better than qSOFA.

Association between prehospital shock index variation and 28-day mortality among patients with septic shock

PURPOSE

Septic shock (SS) hyperdynamic phase is characterized by tachycardia and low-blood pressure reflecting the relative hypovolemia. Shock index (SI), the ratio between heart rate and systolic blood pressure, is a simple objective tool, usable for SS prognosis assessment. This study aims to evaluate the relationship between prehospital SI variation and 28-day mortality of SS patients initially cared for in prehospital setting by a mobile intensive care unit (mICU).

METHODS

From April 6th, 2016 to December 31st, 2020, 406 patients with SS requiring prehospital mICU were retrospectively analyzed. Initial SI, i.e. first measurement after mICU arrival to the scene, and final SI, i.e. last measurement of the prehospital stage, were used to calculate delta SI (initial SI-final SI) and to define positive and negative delta SI. A survival analysis after propensity score matching compared the 28-day mortality of SS patients with positive/negative delta SI.

RESULTS

The main suspected origins of infection were pulmonary (42%), digestive (25%) and urinary (17%). The 28-day overall mortality reached 29%. Cox regression analysis revealed a significant association between 28-day mortality and delta SI. A negative delta SI was associated with an increase in mortality (adjusted hazard ratio (HRa) of 1.88 [1.07-3.31] (p = 0.03)), whereas a positive delta SI was associated with a mortality decrease (HRa = 0.53 [0.30-0.94] (p < 10-3)).

CONCLUSION

Prehospital hemodynamic delta SI among SS patients cared for by a mICU is associated with 28-day mortality. A negative prehospital delta SI could help physicians to identify SS with higher risk of 28-day mortality.

Prognostic Accuracy of qSOFA and SIRS for Mortality in the Emergency Department: A Meta-Analysis and Systematic Review of Prospective Studies

Objective

This meta-analysis aimed to determine the prognostic performance of quick sequential organ failure assessment (qSOFA) score in comparison to systemic inflammatory response syndrome (SIRS) in predicting in-hospital mortality in the emergency department (ED) patients.

Methods

Eligible studies comparing the performance of qSOFA and SIRS in predicting in-hospital death of ED patients were identified from searching PubMed, Embase, and Cochrane. Raw data were collected, and the pooled sensitivity and specificity were calculated for qSOFA and SIRS. The summary receiver operating curve was also plotted to calculate the area under the curve.

Results

A total of 16 prospective studies with 35,756 patients and 2,285 deaths were included. The pooled sensitivity was 0.43 (95% CI: 0.32–0.54) and 0.8 (95% CI: 0.73–0.86) for qSOFA and SIRS, respectively. The pooled specificity was 0.89 (95% CI: 0.84–0.93) and 0.39 (95% CI: 0.3–0.5) for qSOFA and SIRS, respectively. The area under the summary receiver operating curve was 0.76 (95% CI: 0.72–0.8) and 0.67 (95% CI: 0.62–0.72) for qSOFA and SIRS, respectively. A significant heterogeneity was observed for both qSOFA and SIRS studies.

Conclusion

The present meta-analysis suggested that qSOFA had a higher specificity but a lower sensitivity as compared with SIRS in predicting in-hospital mortality in the ED patients. qSOFA appeared to be a more concise and simple way to recognize patients at high risk for death. However, the use of SIRS in the ED cannot be completely replaced since the sensitivity of qSOFA was relatively lower.

SOFA Score Plus Impedance Ratio Predicts Mortality in Critically Ill Patients Admitted to the Emergency Department: Retrospective Observational Study

Background: The Sequential Organ Failure Assessment (SOFA) is a scoring system used for the evaluation of disease severity and prognosis of critically ill patients. The impedance ratio (Imp-R) is a novel mortality predictor. Aims: This study aimed to evaluate the combination of the SOFA + Imp-R in the prediction of mortality in critically ill patients admitted to the Emergency Department (ED). Methods: A retrospective cohort study was performed in adult patients with acute illness admitted to the ED of a tertiary-care referral center. Baseline SOFA score and bioelectrical impedance analysis to obtain the Imp-R were performed within the first 24 h after admission to the ED. A Cox regression analysis was performed to evaluate the mortality risk of the initial SOFA score plus the Imp-R. Harrell’s C-statistic and decision curve analyses (DCA) were performed. Results: Out of 325 patients, 240 were included for analysis. Overall mortality was 31.3%. Only 21.3% of non-surviving patients died after hospital discharge, and 78.4% died during their hospital stay. Of the latter, 40.6% died in the ED. The SOFA and Imp-R values were higher in non-survivors and were significantly associated with mortality in all models. The combination of the SOFA + Imp-R significantly predicted 30-day mortality, in-hospital mortality, and ED mortality with an area under the curve (AUC) of 0.80 (95% CI: 74–0.86), 0.79 (95% CI: 0.74–0.86) and 0.75 (95% CI: 0.66–0.84), respectively. The DCA showed that combining the SOFA + Imp-R improved the prediction of mortality through the lower risk thresholds. Conclusions: The addition of the Imp-R to the baseline SOFA score on admission to the ED improves mortality prediction in severely acutely ill patients admitted to the ED.

A Novel Risk-Prediction Scoring System for Sepsis among Patients with Acute Pancreatitis: A Retrospective Analysis of a Large Clinical Database

Background

The prognosis is poor when acute pancreatitis (AP) progresses to sepsis; therefore, it is necessary to accurately predict the probability of sepsis and develop a personalized treatment plan to reduce the disease burden of AP patients.

Methods

A total of 1295 patients with AP and 43 variables were extracted from the Medical Information Mart for Intensive Care (MIMIC) IV database. The included patients were randomly assigned to the training set and to the validation set at a ratio of 7 : 3. The chi-square test or Fisher's exact test was used to test the distribution of categorical variables, and Student's t-test was used for continuous variables. Multivariate logistic regression was used to establish a prognostic model for predicting the occurrence of sepsis in AP patients. The indicators to verify the overall performance of the model included the area under the receiver operating characteristic curve (AUC), calibration curves, the net reclassification improvement (NRI), the integrated discrimination improvement (IDI), and a decision curve analysis (DCA).

Results

The multifactor analysis results showed that temperature, phosphate, calcium, lactate, the mean blood pressure (MBP), urinary output, Glasgow Coma Scale (GCS), Charlson Comorbidity Index (CCI), sodium, platelet count, and albumin were independent risk factors. All of the indicators proved that the prediction performance and clinical profitability of the newly established nomogram were better than those of other common indicators (including SIRS, BISAP, SOFA, and qSOFA).

Conclusions

The new risk-prediction system that was established in this research can accurately predict the probability of sepsis in patients with acute pancreatitis, and this helps clinicians formulate personalized treatment plans for patients. The new model can reduce the disease burden of patients and can contribute to the reasonable allocation of medical resources, which is significant for tertiary prevention.

A 2-year retrospective analysis of the prognostic value of MqSOFA compared to lactate, NEWS and qSOFA in patients with sepsis

Purpose

Sepsis is a life-threating organ dysfunction caused by a dysregulated host response to infection. Being a time-dependent condition, the present study aims to compare a recently established score, i.e., modified quick SOFA (MqSOFA), with other existing tools commonly applied to predict in-hospital mortality.

Methods

All cases of sepsis and septic shock consecutively observed at St. Anna University Hospital of Ferrara, Italy, from January 2017 to December 2018 were included in this study. Each patient was evaluated with MqSOFA, lactate assay, NEWS and qSOFA. Accurate statistical and logistic regression analyses were applied to our database.

Results

A total of 1001 consecutive patients with sepsis/septic shock were retrieved. Among them, 444 were excluded for incomplete details about vital parameters; thus, 556 patients were eligible for the study. Data analysis showed that MqSOFA, NEWS and lactate assay provided a better predictive ability than qSOFA in terms of in-hospital mortality (p < 0.001). Aetiology-based stratification in 5 subgroups demonstrated the superiority of NEWS vs. other tools in predicting fatal outcomes (p = 0.030 respiratory, p = 0.036 urinary, p = 0.044 abdominal, p = 0.047 miscellaneous and p = 0.041 for indeterminate causes). After Bonferroni’s correction, MqSOFA was superior to qSOFA over respiratory (p < 0.001) and urinary (p < 0.001) aetiologies. Age was an independent factor for negative outcomes (p < 0.001).

Conclusions

MqSOFA, NEWS and lactate assay better predicted in-hospital mortality compared to qSOFA. Since sepsis needs a time-dependent assessment, an easier and non-invasive score, i.e., MqSOFA, could be used to establish patients’ outcome in the emergency setting.

Early warning model for death of sepsis via length insensitive temporal convolutional network

Sepsis is a life-threatening systemic syndrome characterized by various biological, biochemical, and physiological abnormalities. Due to its high mortality, identifying sepsis patients with high risk of in-hospital death early and accurately will help doctors make optimal clinical decisions and reduce the mortality of sepsis patients. In this paper, we propose a length insensitive TCN-based model to predict sepsis patient's death risk in the future k hours, which is the first work for sepsis death risk early warning model only based on vital signs time series to our best knowledge. Furthermore, we design residual connections between temporal residual blocks to improve the prediction performance and stability especially on short input sequences. We validate and evaluate our model on two freely-available datasets, i.e., MIMIC-IV and eICU, from which 16,520 and 29,620 patients are selected respectively. The experiment results show that our model outperforms LSTM and other machine learning methods, as it has the highest sensitivity and Youden index in almost all cases. Meanwhile, the Youden index of the TCN-based model only slightly decreases by 0.0233 and 0.0307 when the time range of the input sequence changes from 24 to 4 h for k equal to 6 and 12, respectively.

Comparison of different versions of the quick sequential organ failure assessment for predicting in-hospital mortality of sepsis patients: A retrospective observational study

BACKGROUND

The quick sequential organ failure assessment (qSOFA) is recommended to identify sepsis and predict sepsis mortality. However, some studies have recently shown its poor performance in sepsis mortality prediction. To enhance its effectiveness, researchers have developed various revised versions of the qSOFA by adding other parameters, such as the lactate-enhanced qSOFA (LqSOFA), the procalcitonin-enhanced qSOFA (PqSOFA), and the modified qSOFA (MqSOFA). This study aimed to compare the performance of these versions of the qSOFA in predicting sepsis mortality in the emergency department (ED).

METHODS

This retrospective study analyzed data obtained from an electronic register system of adult patients with sepsis between January 1 and December 31, 2019. Receiver operating characteristic (ROC) curve analyses were performed to determine the area under the curve (AUC), with sensitivity, specificity, and positive and negative predictive values calculated for the various scores.

RESULTS

Among the 936 enrolled cases, there were 835 survivors and 101 deaths. The AUCs of the LqSOFA, MqSOFA, PqSOFA, and qSOFA were 0.740, 0.731, 0.712, and 0.705, respectively. The sensitivity of the LqSOFA, MqSOFA, PqSOFA, and qSOFA were 64.36%, 51.40%, 71.29%, and 39.60%, respectively. The specificity of the four scores were 70.78%, 80.96%, 61.68%, and 91.62%, respectively. The LqSOFA and MqSOFA were superior to the qSOFA in predicting in-hospital mortality.

CONCLUSIONS

Among patients with sepsis in the ED, the performance of the PqSOFA was similar to that of the qSOFA and the values of the LqSOFA and MqSOFA in predicting in-hospital mortality were greater compared to qSOFA. As the added parameter of the MqSOFA was more convenient compared to the LqSOFA, the MqSOFA could be used as a candidate for the revised qSOFA to increase the performance of the early prediction of sepsis mortality.

Risk factors of sepsis among patients with qSOFA<2 in the emergency department

OBJECTIVE

Studies have suggested that qSOFA can be used for early detection of sepsis immediately upon arrival at the emergency department (ED). Despite this, little is known about the risk factors associated with the subsequent diagnosis of sepsis among patients with qSOFA<2 in the ED.

METHODS

This is a retrospective cohort study using ED data from a large tertiary medical center in Japan, 2018-2020. We included adult patients (aged ≥18 years) presenting to the ED with suspected infection (e.g., having a fever) and qSOFA<2. We identified patients who developed sepsis based on the Sepsis-3 criteria, and compared patient characteristics (e.g., demographics, vital signs upon the initial triage, chief complaint, and comorbidities) between patients who developed sepsis or not. Additionally, we identified the potential risk factors of sepsis among patients with qSOFA<2 using a multivariable logistic regression model.

RESULTS

We identified 151 (7%) patients who developed sepsis among 2025 adult patients with suspected infection and qSOFA<2. Compared with patients who did not develop sepsis, patients who developed sepsis were likely to be older and have vital signs suggestive of imminent sepsis (e.g., high respiratory rate). In the multivariable logistic regression model, the potential risk factors of sepsis among patients with qSOFA<2 were older age (adjusted OR, 1.92 [95%CI 1.19-3.19]), vital signs suggestive of imminent sepsis (e.g., adjusted OR of altered mental status, 3.50 [95%CI 2.25-5.50]), receipt of oxygen therapy upon arrival at the ED (adjusted OR, 1.91 [95%CI 1.38-2.26]), chief complaint of sore throat (adjusted OR, 2.15 [95%CI 1.08-4.13]), and the presence of comorbid diabetes mellitus, ischemic heart disease, and chronic kidney disease (e.g., adjusted OR of diabetes mellitus, 1.47 [95%CI 1.10-1.96]). On the contrary, chief complaint of abdominal and chest pain were associated with a lower risk of sepsis (e.g., adjusted OR of abdominal pain, 0.26 [95%CI 0.14-0.45]).

CONCLUSIONS

We found that older age, vital signs prognosticating sepsis, and the presence of some comorbidities were the potential risk factors of sepsis in patients with qSOFA<2. These potential risk factors could be useful to efficiently recognize patients who might develop sepsis in the ED.

Prognostic scores and early management of septic patients in the emergency department of a secondary hospital: results of a retrospective study

BACKGROUND

Sequential Organ Failure Assessment (SOFA) and other illness prognostic scores predict adverse outcomes in critical patients. Their validation as a decision-making tool in the emergency department (ED) of secondary hospitals is not well established. The aim of this study was to compare SOFA, NEWS2, APACHE II, and SAPS II scores as predictors of adverse outcomes and decision-making tool in ED.

METHODS

Data of 121 patients (age 73 ± 10 years, 58% males, Charlson Comorbidity Index 5.7 ± 2.1) with a confirmed sepsis were included in a retrospective study between January 2017 and February 2020. Scores were computed within the first 24 h after admission. Primary outcome was the occurrence of either in-hospital death or mechanical ventilation within 7 days. Secondary outcome was 30-day all-cause mortality.

RESULTS

Patients older than 64 years (elderly) represent 82% of sample. Primary and secondary outcomes occurred in 40 and 44%, respectively. Median 30-day survival time of dead patients was 4 days (interquartile range 1-11). The best predictive score based on the area under the receiver operating curve (AUROC) was SAPS II (0.823, 95% confidence interval, CI, 0.744-0.902), followed by APACHE II (0.762, 95% CI 0.673-0.850), NEWS2 (0.708, 95% CI 0.616-0.800), and SOFA (0.650, 95% CI 0.548-0.751). SAPS II cut-off of 49 showed the lowest false-positive rate (12, 95% CI 5-20) and the highest positive predictive value (80, 95% CI 68-92), whereas NEWS2 cut-off of 7 showed the lowest false-negative rate (10, 95% CI 2-19) and the highest negative predictive value (86, 95% CI 74-97). By combining NEWS2 and SAPS II cut-offs, we accurately classified 64% of patients. In survival analysis, SAPS II cut-off showed the highest difference in 30-day mortality (Hazards Ratio, HR, 5.24, 95% CI 2.99-9.21, P < 0.001). Best independent negative predictors of 30-day mortality were body temperature, mean arterial pressure, arterial oxygen saturation, and hematocrit levels. Positive predictors were male sex, heart rate and serum sodium concentration.

CONCLUSIONS

SAPS II is a good prognostic tool for discriminating high-risk patient suitable for sub-intensive/intensive care units, whereas NEWS2 for discriminating low-risk patients for low-intensive units. Our results should be limited to cohorts with a high prevalence of elderly or comorbidities.

Prognostic Accuracy of the qSOFA Score for In-Hospital Mortality in Elderly Patients with Obstructive Acute Pyelonephritis: A Multi-Institutional Study

Prognostic accuracy of the quick sequential organ failure assessment (qSOFA) score for mortality may be limited in elderly patients. Using our multi-institutional database, we classified obstructive acute pyelonephritis (OAPN) patients into young and elderly groups, and evaluated predictive performance of the qSOFA score for in-hospital mortality. qSOFA score ≥ 2 was an independent predictor for in-hospital mortality, as was higher age, and Charlson comorbidity index (CCI) ≥ 2. In young patients, the area under the curve (AUC) of the qSOFA score for in-hospital mortality was 0.85, whereas it was 0.61 in elderly patients. The sensitivity and specificity of qSOFA score ≥ 2 for in-hospital mortality was 80% and 80% in young patients, and 50% and 68% in elderly patients, respectively. For elderly patients, we developed the CCI-incorporated qSOFA score, which showed higher prognostic accuracy compared with the qSOFA score (AUC, 0.66 vs. 0.61, p < 0.001). Therefore, the prognostic accuracy of the qSOFA score for in-hospital mortality was high in young OAPN patients, but modest in elderly patients. Although it can work as a screening tool to determine therapeutic management in young patients, for elderly patients, the presence of comorbidities should be considered at the initial assessment.

The timing of use of risk stratification tools affects their ability to predict mortality from sepsis. A meta-regression analysis

Background: Risk stratification tools (RSTs) are used in healthcare settings to identify patients at risk of sepsis and subsequent adverse outcomes. In practice RSTs are used on admission and thereafter as ‘trigger’ tools prompting sepsis management. However, studies investigating their performance report scores at a single timepoint which varies in relation to admission. The aim of this meta-analysis was to determine if the predictive performance of RSTs is altered by the timing of their use. Methods: We conducted a systematic review and meta-regression analysis of studies published from inception to 31 October 2018, using EMBASE and PubMed databases. Any cohort studies investigating the ability of an RST to predict mortality in adult sepsis patients admitted to hospital, from which a 2x2 table was available or could be constructed, were included. The diagnostic performance of RSTs in predicting mortality was the primary outcome. Sensitivity, specificity, positive predictive value, negative predictive value and area under the receiver-operating curve (AUROC) were the primary measures, enabling further meta-regression analysis. Results: 47 studies were included, comprising 430,427 patients. Results of bivariate meta-regression analysis found tools using a first-recorded score were less sensitive than those using worst-recorded score (REML regression coefficient 0.57, 95% CI 0.07-1.08). Using worst-recorded score led to a large increase in sensitivity (summary sensitivity 0.76, 95% CI 0.67-0.83, for worst-recorded scores vs. 0.64 (0.57-0.71) for first-recorded scores). Scoring system type did not have a significant relationship with studies’ predictive ability. The most analysed RSTs were qSOFA (n=37) and EWS (n=14). Further analysis of these RSTs also found timing of their use to be associated with predictive performance. Conclusion: The timing of any RST is paramount to their predictive performance. This must be reflected in their use in practice, and lead to prospective studies in future.

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

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.

Trend and Predictors of Short-term Mortality of Adult Bacteremia at Emergency Departments: A 14-Year Cohort Study of 14 625 Patients

BACKGROUND

Bacteremia is a life-threatening condition with a high mortality rate in critical care and emergency settings. The current study investigated the trend of mortality and developed predictive models of mortality for adults with bacteremia at emergency departments (EDs).

METHODS

We conducted a retrospective cohort study of adults with bacteremia at the ED of China Medical University Hospital. Patient data were obtained from the Clinical Research Data Repository, and mortality information was obtained from the National Death Registry. We developed a new model to predict 7-day mortality in the derivation population and compared the model performance of the new model with Pitt Bacteremia Score (PBS) and Bloodstream Infection Mortality Risk Score (BSIMRS) in the validation population.

RESULTS

We identified 14625 adult patients with first-time bacteremia at the ED, of whom 8.4% died within 7 days. From 2003 to 2016, both the cumulative incidence and 7-day mortality rate of bacteremia decreased significantly. The ED bacteremia mortality (ED-BM) model included PBS parameters, age, infection source, baseline steroid use, and biochemical profiles (estimated glomerular filtration rate, platelet, blood urea nitrogen, potassium, and hemoglobin) for predicting 7-day mortality. The discrimination performance of the ED-BM model (area under curve [AUC], 0.903) was significantly better than that of PBS (AUC, 0.848) or BSIMRS (AUC, 0.885).

CONCLUSIONS

Although the cumulative incidence and mortality of ED bacteremia decreased, its mortality burden remains critical. The proposed ED-BM model had significantly better model performance than other scoring systems in predicting short-term mortality for adult patients with bacteremia at EDs.

Delirium screening with 4AT in patients aged 65 years and older admitted to the Emergency Department with suspected sepsis: a prospective cohort study

Aim

To study delirium screening upon Emergency Department admission among patients admitted with suspected sepsis.

Findings

Delirium screening upon Emergency Department admission, using 4AT, was useful among patients aged ≥65 years admitted with suspected sepsis. Two out of three patients had at least one feature of delirium upon admission.

Message

This study suggest increased awareness of delirium among older patients with suspected sepsis.

Supplementary Information

The online version contains supplementary material available at 10.1007/s41999-021-00558-5.

Purpose

We aimed to study the use of The 4 ‘A’s test (4AT), a rapid delirium screening tool, performed upon Emergency Department (ED) admission, and to characterize older patients admitted to the ED with and without sepsis in terms of delirium features.

Methods

In this prospective cohort study, we included patients aged ≥ 65 years, admitted to the ED with suspected sepsis. ED nurses and doctors performed delirium screening with 4AT within two hours after ED admission, and registered the time spent on the screening in each case. Sepsis and delirium during the hospital stay were diagnosed retrospectively, according to recommended diagnosis criteria.

Results

Out of the 196 patients included (mean age 81 years, 60% men), 100 patients fulfilled the sepsis diagnosis criteria. The mean 4AT screening time was 2.5 Minutes. In total, 114 patients (58%) had a 4AT score ≥ 1, indicating cognitive impairment, upon ED admission. Sepsis patients more often had a 4AT score ≥ 4, indicating delirium, than patients without sepsis (40% vs. 26%, p < 0.05). Out of the 100 patients with sepsis, 68 (68%) had delirium during the hospital stay, as compared to 34 out of 96 patients (35%) without sepsis (p < 0.05).

Conclusion

Delirium screening upon ED admission, using 4AT, was feasible among patients aged ≥ 65 years admitted with suspected sepsis. Two out of three patients had at least one feature of delirium upon admission. The prevalence of delirium during the hospital stay was high, particularly in patients with sepsis.

Graphic abstract

Comparison of Diagnostic Accuracies of qSOFA, NEWS, and MEWS to Identify Sepsis in Older Inpatients With Suspected Infection

OBJECTIVES

To determine and compare the accuracies of the quick Sequential (Sepsis-related) Organ Failure Assessment (qSOFA) and Modified and National Early Warning Scores (NEWS and MEWS) to identify sepsis in older inpatients with suspected infection.

DESIGN

Prospective diagnostic accuracy study.

SETTING AND PARTICIPANTS

Patients admitted to an acute geriatric unit of an Italian University Hospital with at least one sepsis risk factor and suspected infection defined as antibiotic prescription and associated culture test during hospital stay.

METHODS

Sepsis diagnosis was defined as the presence on discharge documents of International Classification of Diseases, Ninth revision, Clinical Modification codes for severe sepsis, septic shock, or for infection and acute organ disfunction. For each patient, clinical parameters were evaluated at least twice daily throughout hospital stay; qSOFA, NEWS, and MEWS were derived, and worst scores recorded. Positive cutoffs were set at ≥2, ≥7, and ≥5, respectively. Sensitivity, specificity, positive and negative predictive values (PPV and NPV, respectively), and positive and negative likelihood ratios, as well as areas under the receiver operating characteristic curve (AUROCs) were calculated.

RESULTS

Among 230 geriatric patients with suspected infection at risk for sepsis (median age 86 years, 49% women), 30.9% had a sepsis diagnosis. A qSOFA ≥2 was recorded in 111 (48.3%) patients, a MEWS ≥5 in 65 (28.3%), and a NEWS ≥7 in 115 (50.0%). The qSOFA showed the highest sensitivity [81.7%, 95% confidence interval (CI) 71.7%-89.5%], but low specificity (66.7%, 95% CI 59.1%-73.7%), resulting in a high NPV (89.1%; 95% CI 82.7%-93.8%) and poor PPV (52.3%, 95% CI 43.0%-61.4%). The AUROC for qSOFA was 0.76 (95% CI 0.69-0.83), comparable with that of NEWS (0.74, 95% CI 0.67-0.81, P = .44), but significantly higher than that of MEWS (0.70, 95% CI 0.63-0.77, P = .04).

CONCLUSIONS AND IMPLICATIONS

Repeated qSOFA determinations are useful to rule out sepsis in geriatric inpatients with suspected infection, but poorly support its diagnosis due to low specificity. More complex MEWS and NEWS do not perform better. Implementation of clinical scores to reliably identify sepsis in older patients is urgently needed.

Performance of scores in the prediction of clinical outcomes in patients admitted from the emergency service

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.

Role of international normalized ratio in nonpulmonary sepsis screening: An observational study

BACKGROUND

Currently, there is a lack of sepsis screening tools that can be widely used worldwide. Pulmonary sepsis can be of sufficient concern to physicians due to their noticeable symptoms, which usually rely less on screening tools.

AIM

To investigate the efficiency of the international normalized ratio (INR) for the early rapid recognition of adult nonpulmonary infectious sepsis.

METHODS

This is a prospective observational study. A total of 108 sepsis patients and 106 nonsepsis patients were enrolled according to relevant inclusion and exclusion criteria. Commonly used clinical indicators, such as white blood cell, neutrophil count, lymphocyte count, neutrophil-lymphocyte count ratio (NLCR), platelets (PLT), prothrombin time, INR, activated partial thromboplastin time, and quick Sequential “Sepsis-related” Organ Failure Assessment (qSOFA) scores were recorded within 24 h after admission. The diagnostic performances of these clinical indicators were analyzed and compared through multivariate logistic regression analysis, Spearman correlation, and receiver operating characteristic curve analysis.

RESULTS

The INR value of the sepsis group was significantly higher than that of the nonsepsis group. INR has superior diagnostic efficacy for sepsis, with an area under the curve value of 0.918, when those preexisting diseases which significantly affect coagulation function were excluded. The diagnostic efficacy of the INR was more significant than that of NLCR, PLT, and qSOFA (P < 0.05). Moreover, INR levels of 1.17, 1.20, and 1.22 could be used to categorize the relative risk of nonpulmonary infections sepsis into three categories: low, medium and high risk, respectively.

CONCLUSION

The INR is a promising and easily available biomarker for diagnosis, and it can be used as one of the indicators for early screening of adult nonpulmonary infectious sepsis. When its value is higher than the optimal cutoff value (1.22), high vigilance is required for adult nonpulmonary infectious 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.

Monocyte distribution width (MDW) as a screening tool for sepsis in the Emergency Department

Objectives The diagnosis of sepsis in the Emergency Department (ED) is challenging and a reliable biomarker is needed. The current study aimed to evaluate the diagnostic accuracy of monocyte distribution width (MDW) for the early identification of sepsis in the ED. Methods We performed a large observational study including consecutive adult patients (≥18 years of age) presenting to the ED between September and November 2019, with an order for complete blood count (CBC) evaluation. A total of 2,215 patients were enrolled and classified based on Sepsis-2 criteria as the control group (1,855), infection group (172), Systemic Inflammatory Response Syndrome (SIRS) group (100), and sepsis group (88). Results MDW levels were higher in patients with sepsis than in all other groups (p<0.001). ROC curve analysis showed an optimal diagnostic accuracy of MDW for sepsis prediction at a cut-off point of 23.5, with an AUC of 0.964, sensitivity and specificity of 0.920 and 0.929, respectively. Conclusions Our findings encourage further investigation to validate the use of MDW as a screening tool for the early identification of patients at risk of sepsis in the ED.