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Orsatti VN, Ribeiro VST, de Oliveira Montenegro C, Costa CJ, Raboni EA, Sampaio ER, Michielin F, Gasparetto J, Telles JP, Tuon FF. Sepsis death risk factor score based on systemic inflammatory response syndrome, quick sequential organ failure assessment, and comorbidities. Med Intensiva 2024; 48:263-271. [PMID: 38575400 DOI: 10.1016/j.medine.2024.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/06/2024]
Abstract
OBJECTIVE In this study, we aimed to evaluate the death risk factors of patients included in the sepsis protocol bundle, using clinical data from qSOFA, SIRS, and comorbidities, as well as development of a mortality risk score. DESIGN This retrospective cohort study was conducted between 2016 and 2021. SETTING Two university hospitals in Brazil. PARTICIPANTS Patients with sepsis. INTERVENTIONS Several clinical and laboratory data were collected focused on SIRS, qSOFA, and comorbidities. MAIN VARIABLE OF INTEREST In-hospital mortality was the primary outcome variable. A mortality risk score was developed after logistic regression analysis. RESULTS A total of 1,808 patients were included with a death rate of 36%. Ten variables remained independent factors related to death in multivariate analysis: temperature ≥38 °C (odds ratio [OR] = 0.65), previous sepsis (OR = 1.42), qSOFA ≥ 2 (OR = 1.43), leukocytes >12,000 or <4,000 cells/mm3 (OR = 1.61), encephalic vascular accident (OR = 1.88), age >60 years (OR = 1.93), cancer (OR = 2.2), length of hospital stay before sepsis >7 days (OR = 2.22,), dialysis (OR = 2.51), and cirrhosis (OR = 3.97). Considering the equation of the binary regression logistic analysis, the score presented an area under curve of 0.668, is not a potential model for death prediction. CONCLUSIONS Several risk factors are independently associated with mortality, allowing the development of a prediction score based on qSOFA, SIRS, and comorbidities data, however, the performance of this score is low.
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Affiliation(s)
- Vinicius Nakad Orsatti
- Laboratory of Emerging Infectious Diseases, School of Medicine, Pontifícia Universidade Católica do Paraná, Curitiba, PR, 80215-901, Brazil
| | - Victoria Stadler Tasca Ribeiro
- Laboratory of Emerging Infectious Diseases, School of Medicine, Pontifícia Universidade Católica do Paraná, Curitiba, PR, 80215-901, Brazil
| | - Carolina de Oliveira Montenegro
- Laboratory of Emerging Infectious Diseases, School of Medicine, Pontifícia Universidade Católica do Paraná, Curitiba, PR, 80215-901, Brazil
| | - Clarice Juski Costa
- Laboratory of Emerging Infectious Diseases, School of Medicine, Pontifícia Universidade Católica do Paraná, Curitiba, PR, 80215-901, Brazil
| | - Eduardo Albanske Raboni
- Laboratory of Emerging Infectious Diseases, School of Medicine, Pontifícia Universidade Católica do Paraná, Curitiba, PR, 80215-901, Brazil
| | - Eduardo Ramos Sampaio
- Laboratory of Emerging Infectious Diseases, School of Medicine, Pontifícia Universidade Católica do Paraná, Curitiba, PR, 80215-901, Brazil
| | - Fernando Michielin
- Laboratory of Emerging Infectious Diseases, School of Medicine, Pontifícia Universidade Católica do Paraná, Curitiba, PR, 80215-901, Brazil
| | - Juliano Gasparetto
- Laboratory of Emerging Infectious Diseases, School of Medicine, Pontifícia Universidade Católica do Paraná, Curitiba, PR, 80215-901, Brazil
| | - João Paulo Telles
- Laboratory of Emerging Infectious Diseases, School of Medicine, Pontifícia Universidade Católica do Paraná, Curitiba, PR, 80215-901, Brazil
| | - Felipe Francisco Tuon
- Laboratory of Emerging Infectious Diseases, School of Medicine, Pontifícia Universidade Católica do Paraná, Curitiba, PR, 80215-901, Brazil.
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Abstract
Severe pneumonia is associated with high mortality (short and long term), as well as pulmonary and extrapulmonary complications. Appropriate diagnosis and early initiation of adequate antimicrobial treatment for severe pneumonia are crucial in improving survival among critically ill patients. Identifying the underlying causative pathogen is also critical for antimicrobial stewardship. However, establishing an etiological diagnosis is challenging in most patients, especially in those with chronic underlying disease; those who received previous antibiotic treatment; and those treated with mechanical ventilation. Furthermore, as antimicrobial therapy must be empiric, national and international guidelines recommend initial antimicrobial treatment according to the location's epidemiology; for patients admitted to the intensive care unit, specific recommendations on disease management are available. Adherence to pneumonia guidelines is associated with better outcomes in severe pneumonia. Yet, the continuing and necessary research on severe pneumonia is expansive, inviting different perspectives on host immunological responses, assessment of illness severity, microbial causes, risk factors for multidrug resistant pathogens, diagnostic tests, and therapeutic options.
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Affiliation(s)
- Catia Cillóniz
- Department of pneumology, Hospital Clinic of Barcelona, Spain
- August Pi i Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain
- University of Barcelona, Barcelona, Spain
- Biomedical Research Networking Centers in Respiratory Diseases (CIBERES), Barcelona, Spain
| | - Antoni Torres
- Department of pneumology, Hospital Clinic of Barcelona, Spain
- August Pi i Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain
- University of Barcelona, Barcelona, Spain
- Biomedical Research Networking Centers in Respiratory Diseases (CIBERES), Barcelona, Spain
| | - Michael S Niederman
- Weill Cornell Medical College, Department of Pulmonary Critical Care Medicine, New York, NY, USA
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3
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Flint M, Hamilton F, Arnold D, Carlton E, Hettle D. The timing of use of risk stratification tools affects their ability to predict mortality from sepsis. A meta-regression analysis. Wellcome Open Res 2021. [DOI: 10.12688/wellcomeopenres.17223.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
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.
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Guo Q, Li HY, Song WD, Liu H, Yu HQ, Li YH, Lü ZD, Liang LH, Zhao QZ, Jiang M. qSOFA predicted pneumonia mortality better than minor criteria and worse than CURB-65 with robust elements and higher convergence. Am J Emerg Med 2021; 52:1-7. [PMID: 34856439 DOI: 10.1016/j.ajem.2021.11.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Revised: 11/13/2021] [Accepted: 11/18/2021] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Limited data are available on the discriminatory capacity of quick sequential [sepsis-related] organ failure assessment (qSOFA) versus IDSA/ATS minor criteria for predicting mortality in patients with community-acquired pneumonia (CAP). METHODS An observational prospective cohort study of 2116 patients with CAP was performed. Construct validity was determined using Cronbach α. Discrimination was assessed using the area under the receiver operating characteristic curve (AUROC) and net reclassification improvement (NRI). RESULTS Overall in-hospital mortality was 6.43%. Mortality was 25.96% for patients with a qSOFA score of 2 or higher versus 3.05% for those with a qSOFA score less than 2 (odds ratio for mortality 6.57, P < 0.0001), and 13.85% for patients with at least 3 minor criteria versus 2.03% for those with 2 or fewer minor criteria (odds ratio for mortality 2.27, P < 0.0001). qSOFA had a higher correlation with mortality than minor criteria, as well as higher internal consistency (Cronbach alpha 0.43 versus 0.14) and diagnostic values of individual elements (larger AUROCs and higher Youden's indices). qSOFA ≥2 was less sensitive but more specific for predicting mortality than ≥3 minor criteria (qSOFA sensitivity 59.6%, specificity 88.3% and positive likelihood ratio 5.11 versus ≥3 minor criteria sensitivity 80.1%, specificity 65.8% and positive likelihood ratio 2.34). The predictive validity of qSOFA was good for mortality (AUROC = 0.868), was statistically greater than minor criteria, was equal to pneumonia severity index, and was inferior compared with CURB-65 (AUROC, 0.824, 0.902, 0.919; NRI, 0.088, -0.068, -0.103; respectively). CONCLUSIONS The qSOFA predicted mortality in CAP better than IDSA/ATS minor criteria and worse than CURB-65 with robust elements and higher convergence. qSOFA as a bedside prompt might be positioned as a proxy for minor criteria and increase the recognition and thus merit more appropriate management of CAP patients likely to fare poorly, which might have implications for more accurate clinical triage decisions.
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Affiliation(s)
- Qi Guo
- Department of Pulmonary and Critical Care Medicine, Shenzhen Hospital, Peking University, Shenzhen, 518036, Guangdong, China; Department of Pulmonary and Critical Care Medicine, The Eighth Affiliated Hospital (Shenzhen Futian), Sun Yat-sen University, Shenzhen, 518033, Guangdong, China.
| | - Hai-Yan Li
- Department of General Medicine, The Eighth Affiliated Hospital (Shenzhen Futian), Sun Yat-sen University, Shenzhen, 518033, Guangdong, China
| | - Wei-Dong Song
- Department of Pulmonary and Critical Care Medicine, Shenzhen Hospital, Peking University, Shenzhen, 518036, Guangdong, China
| | - Hui Liu
- Department of Pulmonary and Critical Care Medicine, The Eighth Affiliated Hospital (Shenzhen Futian), Sun Yat-sen University, Shenzhen, 518033, Guangdong, China
| | - Hai-Qiong Yu
- Department of Pulmonary and Critical Care Medicine, The Eighth Affiliated Hospital (Shenzhen Futian), Sun Yat-sen University, Shenzhen, 518033, Guangdong, China
| | - Yan-Hong Li
- Department of Pulmonary and Critical Care Medicine, Shenzhen Hospital, Peking University, Shenzhen, 518036, Guangdong, China
| | - Zhong-Dong Lü
- Department of Pulmonary and Critical Care Medicine, Shenzhen Hospital, Peking University, Shenzhen, 518036, Guangdong, China
| | - Li-Hua Liang
- Department of Radiology, The Eighth Affiliated Hospital (Shenzhen Futian), Sun Yat-sen University, Shenzhen 518033, Guangdong, China
| | - Qing-Zhou Zhao
- Department of Radiology, The Eighth Affiliated Hospital (Shenzhen Futian), Sun Yat-sen University, Shenzhen 518033, Guangdong, China
| | - Mei Jiang
- State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, The First Affiliated Hospital, Guangzhou Medical University, Guangzhou, 510120, Guangdong, China
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5
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Ewig S, Kolditz M, Pletz M, Altiner A, Albrich W, Drömann D, Flick H, Gatermann S, Krüger S, Nehls W, Panning M, Rademacher J, Rohde G, Rupp J, Schaaf B, Heppner HJ, Krause R, Ott S, Welte T, Witzenrath M. [Management of Adult Community-Acquired Pneumonia and Prevention - Update 2021 - Guideline of the German Respiratory Society (DGP), the Paul-Ehrlich-Society for Chemotherapy (PEG), the German Society for Infectious Diseases (DGI), the German Society of Medical Intensive Care and Emergency Medicine (DGIIN), the German Viological Society (DGV), the Competence Network CAPNETZ, the German College of General Practitioneers and Family Physicians (DEGAM), the German Society for Geriatric Medicine (DGG), the German Palliative Society (DGP), the Austrian Society of Pneumology Society (ÖGP), the Austrian Society for Infectious and Tropical Diseases (ÖGIT), the Swiss Respiratory Society (SGP) and the Swiss Society for Infectious Diseases Society (SSI)]. Pneumologie 2021; 75:665-729. [PMID: 34198346 DOI: 10.1055/a-1497-0693] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The present guideline provides a new and updated concept of the management of adult patients with community-acquired pneumonia. It replaces the previous guideline dating from 2016.The guideline was worked out and agreed on following the standards of methodology of a S3-guideline. This includes a systematic literature search and grading, a structured discussion of recommendations supported by the literature as well as the declaration and assessment of potential conflicts of interests.The guideline has a focus on specific clinical circumstances, an update on severity assessment, and includes recommendations for an individualized selection of antimicrobial treatment.The recommendations aim at the same time at a structured assessment of risk for adverse outcome as well as an early determination of treatment goals in order to reduce mortality in patients with curative treatment goal and to provide palliation for patients with treatment restrictions.
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Affiliation(s)
- S Ewig
- Thoraxzentrum Ruhrgebiet, Kliniken für Pneumologie und Infektiologie, EVK Herne und Augusta-Kranken-Anstalt Bochum
| | - M Kolditz
- Universitätsklinikum Carl-Gustav Carus, Klinik für Innere Medizin 1, Bereich Pneumologie, Dresden
| | - M Pletz
- Universitätsklinikum Jena, Institut für Infektionsmedizin und Krankenhaushygiene, Jena
| | - A Altiner
- Universitätsmedizin Rostock, Institut für Allgemeinmedizin, Rostock
| | - W Albrich
- Kantonsspital St. Gallen, Klinik für Infektiologie/Spitalhygiene
| | - D Drömann
- Universitätsklinikum Schleswig-Holstein, Medizinische Klinik III - Pulmologie, Lübeck
| | - H Flick
- Medizinische Universität Graz, Universitätsklinik für Innere Medizin, Klinische Abteilung für Lungenkrankheiten, Graz
| | - S Gatermann
- Ruhr Universität Bochum, Abteilung für Medizinische Mikrobiologie, Bochum
| | - S Krüger
- Kaiserswerther Diakonie, Florence Nightingale Krankenhaus, Klinik für Pneumologie, Kardiologie und internistische Intensivmedizin, Düsseldorf
| | - W Nehls
- Helios Klinikum Erich von Behring, Klinik für Palliativmedizin und Geriatrie, Berlin
| | - M Panning
- Universitätsklinikum Freiburg, Department für Medizinische Mikrobiologie und Hygiene, Freiburg
| | - J Rademacher
- Medizinische Hochschule Hannover, Klinik für Pneumologie, Hannover
| | - G Rohde
- Universitätsklinikum Frankfurt, Medizinische Klinik I, Pneumologie und Allergologie, Frankfurt/Main
| | - J Rupp
- Universitätsklinikum Schleswig-Holstein, Klinik für Infektiologie und Mikrobiologie, Lübeck
| | - B Schaaf
- Klinikum Dortmund, Klinik für Pneumologie, Infektiologie und internistische Intensivmedizin, Dortmund
| | - H-J Heppner
- Lehrstuhl Geriatrie Universität Witten/Herdecke, Helios Klinikum Schwelm, Klinik für Geriatrie, Schwelm
| | - R Krause
- Medizinische Universität Graz, Universitätsklinik für Innere Medizin, Klinische Abteilung für Infektiologie, Graz
| | - S Ott
- St. Claraspital Basel, Pneumologie, Basel, und Universitätsklinik für Pneumologie, Universitätsspital Bern (Inselspital) und Universität Bern
| | - T Welte
- Medizinische Hochschule Hannover, Klinik für Pneumologie, Hannover
| | - M Witzenrath
- Charité, Universitätsmedizin Berlin, Medizinische Klinik mit Schwerpunkt Infektiologie und Pneumologie, Berlin
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Shiraishi A, Gando S, Abe T, Kushimoto S, Mayumi T, Fujishima S, Hagiwara A, Shiino Y, Shiraishi SI, Hifumi T, Otomo Y, Okamoto K, Sasaki J, Takuma K, Yamakawa K, Hanaki Y, Harada M, Morino K. Quick sequential organ failure assessment versus systemic inflammatory response syndrome criteria for emergency department patients with suspected infection. Sci Rep 2021; 11:5347. [PMID: 33674716 PMCID: PMC7935946 DOI: 10.1038/s41598-021-84743-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2020] [Accepted: 02/17/2021] [Indexed: 12/26/2022] Open
Abstract
Previous studies have shown inconsistent prognostic accuracy for mortality with both quick sequential organ failure assessment (qSOFA) and the systemic inflammatory response syndrome (SIRS) criteria. We aimed to validate the accuracy of qSOFA and the SIRS criteria for predicting in-hospital mortality in patients with suspected infection in the emergency department. A prospective study was conducted including participants with suspected infection who were hospitalised or died in 34 emergency departments in Japan. Prognostic accuracy of qSOFA and SIRS criteria for in-hospital mortality was assessed by the area under the receiver operating characteristic (AUROC) curve. Of the 1060 participants, 402 (37.9%) and 915 (86.3%) had qSOFA ≥ 2 and SIRS criteria ≥ 2 (given thresholds), respectively, and there were 157 (14.8%) in-hospital deaths. Greater accuracy for in-hospital mortality was shown with qSOFA than with the SIRS criteria (AUROC: 0.64 versus 0.52, difference + 0.13, 95% CI [+ 0.07, + 0.18]). Sensitivity and specificity for predicting in-hospital mortality at the given thresholds were 0.55 and 0.65 based on qSOFA and 0.88 and 0.14 based on SIRS criteria, respectively. To predict in-hospital mortality in patients visiting to the emergency department with suspected infection, qSOFA was demonstrated to be modestly more accurate than the SIRS criteria albeit insufficiently sensitive.Clinical Trial Registration: The study was pre-registered in the University Hospital Medical Information Network Clinical Trials Registry (UMIN000027258).
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Affiliation(s)
- Atsushi Shiraishi
- Emergency and Trauma Center, Kameda Medical Center, 929, Higashicho, Kamogawa, Chiba, 296-8602, Japan.
| | - Satoshi Gando
- Division of Acute and Critical Care Medicine, Hokkaido University Graduate School of Medicine, Sapporo, Japan.,Department of Acute and Critical Care Medicine, Sapporo Higashi Tokushukai Hospital, Sapporo, Japan
| | - Toshikazu Abe
- Department of General Medicine, Juntendo University, Tokyo, Japan.,Health Services Research and Development Center, University of Tsukuba, Tsukuba, Japan
| | - Shigeki Kushimoto
- Division of Emergency and Critical Care Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Toshihiko Mayumi
- Department of Emergency Medicine, School of Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Seitaro Fujishima
- Center for General Medicine Education, Keio University School of Medicine, Tokyo, Japan
| | - Akiyoshi Hagiwara
- Center Hospital of the National Center for Global Health and Medicine, Tokyo, Japan.,Department of Emergency Medicine, Niizashiki Chuo General Hospital, Niiza, Japan
| | - Yasukazu Shiino
- Department of Acute Medicine, Kawasaki Medical School, Kurashiki, Japan
| | - Shin-Ichiro Shiraishi
- Department of Emergency and Critical Care Medicine, Aizu Chuo Hospital, Aizuwakamatsu, Japan
| | - Toru Hifumi
- Department of Emergency and Critical Care Medicine, St. Luke's International Hospital, Tokyo, Japan
| | - Yasuhiro Otomo
- Trauma and Acute Critical Care Center, Medical Hospital, Tokyo Medical and Dental University, Tokyo, Japan
| | - Kohji Okamoto
- Department of Surgery, Center for Gastroenterology and Liver Disease, Kitakyushu City Yahata Hospital, Kitakyushu, Japan
| | - Junichi Sasaki
- Department of Emergency and Critical Care Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Kiyotsugu Takuma
- Emergency and Critical Care Center, Kawasaki Municipal Kawasaki Hospital, Kawasaki, Japan
| | - Kazuma Yamakawa
- Division of Trauma and Surgical Critical Care, Osaka General Medical Center, Osaka, Japan
| | - Yoshihiro Hanaki
- Department of Emergency and Critical Care Medicine, Japanese Red Cross Nagoya Daiichi Hospital, Nagoya, Japan
| | - Masahiro Harada
- Department of Emergency and Critical Care, National Hospital Organization Kumamoto Medical Center, Kumamoto, Japan
| | - Kazuma Morino
- Medical Center for Emergency, Yamagata Prefectural Central Hospital, Yamagata, Japan
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7
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Spagnolello O, Ceccarelli G, Borrazzo C, Macrì A, Suppa M, Baldini E, Garramone A, Alessandri F, Celani L, Vullo F, Angeletti S, Ciccozzi M, Mastroianni C, Bertazzoni G, D'Ettorre G. qSOFA as a new community-acquired pneumonia severity score in the emergency setting. Emerg Med J 2020; 38:906-912. [PMID: 33023921 DOI: 10.1136/emermed-2019-208789] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Revised: 12/31/2019] [Accepted: 08/23/2020] [Indexed: 11/03/2022]
Abstract
BACKGROUND Quick Sequential Organ Failure Assessment (qSOFA) score is a bedside prognostic tool for patients with suspected infection outside the intensive care unit (ICU), which is particularly useful when laboratory analyses are not readily available. However, its performance in potentially septic patients with community-acquired pneumonia (CAP) needs to be examined further, especially in relation to early outcomes affecting acute management. OBJECTIVE First, to compare the performance of qSOFA and CURB-65 in the prediction of mortality in the emergency department in patients presenting with CAP. Second, to study patients who required critical care support (CCS) and ICU admission. METHODS Between January and December 2017, a 1-year retrospective observational study was carried out of adult (≥18 years old) patients presenting to the emergency department (ED) of our hospital (Rome, Italy) with CAP. The accuracy of qSOFA, qSOFA-65 and CURB-65 was compared in predicting mortality in the ED, CCS requirement and ICU admission. The concordance among scores ≥2 was then assessed for 30-day estimated mortality prediction. RESULTS 505 patients with CAP were enrolled. Median age was 71.0 years and mortality rate in the ED was 4.7%. The areas under the curve (AUCs) of qSOFA-65, CURB-65 and qSOFA in predicting mortality rate in the ED were 0.949 (95% CI 0.873 to 0.976), 0.923 (0.867 to 0.980) and 0.909 (0.847 to 0.971), respectively. The likelihood ratio of a patient having a qSOFA score ≥2 points was higher than for qSOFA-65 or CURB-65 (11 vs 7 vs 6.7). The AUCs of qSOFA, qSOFA-65 and CURB-65 in predicting CCS requirement were 0.862 (95% CI 0.802 to 0.923), 0.824 (0.758 to 0.890) and 0.821 (0.754 to 0.888), respectively. The AUCs of qSOFA-65, qSOFA and CURB-65 in predicting ICU admission were 0.593 (95% CI 0.511 to 0.676), 0.585 (0.503 to 0.667) and 0.570 (0.488 to 0.653), respectively. The concordance between qSOFA-65 and CURB-65 in 30-day estimated mortality prediction was 93%. CONCLUSION qSOFA is a valuable score for predicting mortality in the ED and for the prompt identification of patients with CAP requiring CCS. qSOFA-65 may further improve the performance of this useful score, showing also good concordance with CURB-65 in 30-day estimated mortality prediction.
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Affiliation(s)
- Ornella Spagnolello
- Department of Emergency Medicine, University of Rome La Sapienza, Roma, Lazio, Italy .,Department of Public Health and Infectious Diseases, University of Rome La Sapienza, Roma, Lazio, Italy
| | - Giancarlo Ceccarelli
- Department of Public Health and Infectious Diseases, University of Rome La Sapienza, Roma, Lazio, Italy
| | - Cristian Borrazzo
- Statistical Unit, Department of Public Health and Infectious Diseases, University of Rome La Sapienza, Roma, Lazio, Italy
| | - Angela Macrì
- Department of Emergency Medicine, University of Rome La Sapienza, Roma, Lazio, Italy
| | - Marianna Suppa
- Department of Emergency Medicine, University of Rome La Sapienza, Roma, Lazio, Italy
| | - Enrico Baldini
- Department of Emergency Medicine, University of Rome La Sapienza, Roma, Lazio, Italy
| | - Alessia Garramone
- Department of Emergency Medicine, University of Rome La Sapienza, Roma, Lazio, Italy
| | - Francesco Alessandri
- Department of Anesthesia and Intensive Care Medicine, University of Rome La Sapienza, Roma, Lazio, Italy
| | - Luigi Celani
- Department of Public Health and Infectious Diseases, University of Rome La Sapienza, Roma, Lazio, Italy
| | - Francesco Vullo
- Department of Radiological, Oncological and Anatomo Pathological Sciences, University of Rome La Sapienza, Roma, Lazio, Italy
| | - Silvia Angeletti
- Unit of Clinical Laboratory Science, University Campus Bio-Medico University of Rome Faculty of Medicine and Surgery, Roma, Lazio, Italy
| | - Massimo Ciccozzi
- Unit of Medical Statistics and Molecular Epidemiology, University Campus Bio-Medico University of Rome Faculty of Medicine and Surgery, Roma, Lazio, Italy
| | - Claudio Mastroianni
- Department of Public Health and Infectious Diseases, University of Rome La Sapienza, Roma, Lazio, Italy
| | - Giuliano Bertazzoni
- Department of Emergency Medicine, University of Rome La Sapienza, Roma, Lazio, Italy
| | - Gabriella D'Ettorre
- Department of Public Health and Infectious Diseases, University of Rome La Sapienza, Roma, Lazio, Italy
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8
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Fernandes S, Wyawahare M. Utility of quick sepsis-related organ failure assessment (qSOFA) score to predict outcomes in out-of-ICU patients with suspected infections. J Family Med Prim Care 2020; 9:3251-3255. [PMID: 33102279 PMCID: PMC7567244 DOI: 10.4103/jfmpc.jfmpc_150_20] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Revised: 03/13/2020] [Accepted: 06/19/2020] [Indexed: 01/28/2023] Open
Abstract
Background: Referral of sepsis patients at the level of primary care is often delayed due to the lack of an assessment tool which effectively predicts sepsis. The quick Sepsis-related Organ Failure Assessment score (qSOFA) can be used in such scenarios to improve patient outcomes. Aim: To assess the prognostic accuracy of qSOFA score in predicting adverse outcomes in patients with suspected infections and to compare it with the SIRS (Systemic Inflammatory Response Syndrome) and the SOFA (Sequential Organ failure Assessment Score). Methods: This study included 180 participants admitted in the emergency wards of the Department of Medicine, over a period of one year with suspected infection. The primary outcome was the combined outcome of mortality and/or ICU stay of more than three days. Secondary outcomes were the duration of ICU stay, duration of inotrope use, and duration of mechanical ventilation. Statistical Analysis: Descriptive statistics using SPSS version 19.0 was applied in the study. Results: Of the 180 participants, 54 had a qSOFA score of 2 at admission, 52 participants had an SIRS score of 2. The qSOFA score had the highest AUC for both mortality and the combined outcome of mortality and prolonged ICU stay (0.740 and 0.835, respectively). For a combined outcome of mortality and ICU stay >3 days, the qSOFA score had a sensitivity of 75% and a specificity of 82%. The positive likelihood ratio was 4.17. Conclusion: In a primary care setting, the qSOFA score of more than 2 can be used reliably to refer patients for admission and intensive care as they are likely to need longer hospital stay and can have worse outcomes.
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Chu SE, Seak CJ, Su TH, Chaou CH, Tseng HJ, Li CH. Prognostic accuracy of SIRS criteria and qSOFA score for in-hospital mortality among influenza patients in the emergency department. BMC Infect Dis 2020; 20:385. [PMID: 32471385 PMCID: PMC7256917 DOI: 10.1186/s12879-020-05102-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2020] [Accepted: 05/17/2020] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND The seasonal influenza epidemic is an important public health issue worldwide. Early predictive identification of patients with potentially worse outcome is important in the emergency department (ED). Similarly as with bacterial infection, influenza can cause sepsis. This study was conducted to investigate the effectiveness of the Systemic Inflammatory Response Syndrome (SIRS) criteria and the quick Sequential Organ Failure Assessment (qSOFA) score as prognostic predictors for ED patients with influenza. METHODS This single-center, retrospective cohort study investigated data that was retrieved from a hospital-based research database. Adult ED patients (age ≥ 18 at admission) with laboratory-proven influenza from 2010 to 2016 were included for data analysis. The initial SIRS and qSOFA scores were both collected. The primary outcome was the utility of each score in the prediction of in-hospital mortality. RESULTS For the study period, 3561 patients met the study inclusion criteria. The overall in-hospital mortality was 2.7% (95 patients). When the qSOFA scores were 0, 1, 2, and 3, the percentages of in-hospital mortality were 0.6, 7.2, 15.9, and 25%, respectively. Accordingly, the odds ratios (ORs) were 7.72, 11.92, and 22.46, respectively. The sensitivity and specificity was 24 and 96.2%, respectively, when the qSOFA score was ≥2. However, the SIRS criteria showed no significant associations with the primary outcome. The area under the receiver operating characteristic curve (AUC) was 0.864, which is significantly higher than that with SIRS, where the AUC was 0.786 (P < 0.01). CONCLUSIONS The qSOFA score potentially is a useful prognostic predictor for influenza and could be applied in the ED as a risk stratification tool. However, qSOFA may not be a good screening tool for triage because of its poor sensitivity. The SIRS criteria showed poor predictive performance in influenza for mortality as an outcome. Further research is needed to determine the role of these predictive tools in influenza and in other viral infections.
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Affiliation(s)
- Sheng-En Chu
- Department of Emergency Medicine, Linkou Medical Center, Chang-Gung Memorial Hospital, Taoyuan, Taiwan.,Department of Emergency Medicine, Far Eastern Memorial Hospital, New Taipei City, Taiwan.,College of Medicine, Chang-Gung University, Taoyuan, Taiwan
| | - Chen-June Seak
- Department of Emergency Medicine, Linkou Medical Center, Chang-Gung Memorial Hospital, Taoyuan, Taiwan.,College of Medicine, Chang-Gung University, Taoyuan, Taiwan
| | - Tse-Hsuan Su
- Department of Emergency Medicine, Linkou Medical Center, Chang-Gung Memorial Hospital, Taoyuan, Taiwan.,College of Medicine, Chang-Gung University, Taoyuan, Taiwan
| | - Chung-Hsien Chaou
- Department of Emergency Medicine, Linkou Medical Center, Chang-Gung Memorial Hospital, Taoyuan, Taiwan.,College of Medicine, Chang-Gung University, Taoyuan, Taiwan.,Chang Gung Medical Education Research Centre, Chang-Gung Memorial Hospital, Taoyuan, Taiwan
| | - Hsiao-Jung Tseng
- Clinical Trial Center, Chang-Gung Memorial Hospital, Taoyuan, Taiwan
| | - Chih-Huang Li
- Department of Emergency Medicine, Linkou Medical Center, Chang-Gung Memorial Hospital, Taoyuan, Taiwan. .,College of Medicine, Chang-Gung University, Taoyuan, Taiwan. .,Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang-Gung University, Taoyuan, Taiwan.
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10
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Community-Acquired Pneumonia. Spanish Society of Pulmonology and Thoracic Surgery (SEPAR) Guidelines. 2020 Update. Arch Bronconeumol 2020. [PMID: 32139236 DOI: 10.1016/j.arbres.2020.01.014] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
The guidelines for community-acquired pneumonia, last published in 2010, have been updated to provide recommendations based on a critical summary of the latest literature to help health professionals make the best decisions in the care of immunocompetent adult patients. The methodology was based on 6 PICO questions (on etiological studies, assessment of severity and decision to hospitalize, antibiotic treatment and duration, and pneumococcal conjugate vaccination), agreed by consensus among a working group of pulmonologists and an expert in documentation science and methodology. A comprehensive review of the literature was performed for each PICO question, and these were evaluated in in-person meetings. The American Thoracic Society guidelines were published during the preparation of this paper, so the recommendations of this association were also evaluated. We concluded that the etiological source of the infection should be investigated in hospitalized patients who have suspected resistance or who fail to respond to treatment. Prognostic scales, such as PSI, CURB 65, and CRB65, are useful for assessing severity and the decision to hospitalize. Different antibiotic regimens are indicated, depending on the treatment setting - outpatient, hospital, or intensive care unit - and the resistance of PES microorganisms should be calculated. The minimum duration of antibiotic treatment should be 5 days, based on criteria of clinical stability. Finally, we reviewed the indication of the 13-valent conjugate vaccine in immunocompetent patients with risk factors and comorbidity.
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11
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George N, Elie-Turenne MC, Seethala RR, Baslanti TO, Bozorgmehri S, Mark K, Meurer D, Bihorac A, Aisiku IP, Hou PC. External Validation of the qSOFA Score in Emergency Department Patients With Pneumonia. J Emerg Med 2019; 57:755-764. [DOI: 10.1016/j.jemermed.2019.08.043] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Revised: 08/18/2019] [Accepted: 08/26/2019] [Indexed: 10/25/2022]
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12
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Antibiotic de-escalation therapy in patients with community-acquired nonbacteremic pneumococcal pneumonia. Int J Clin Pharm 2019; 41:1611-1617. [PMID: 31654366 DOI: 10.1007/s11096-019-00926-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2019] [Accepted: 10/04/2019] [Indexed: 10/25/2022]
Abstract
Background De-escalation therapy is recommended as an effective antibiotic treatment strategy for several infectious diseases. While there is limited evidence supporting its clinical and cost-effective outcomes in patients with community-acquired bacteremic pneumonia, there is no evidence in patients with nonbacteremic pneumonia. Objective This study aimed to evaluate the antibiotic costs in patients who did and did not receive de-escalation therapy, based on the 2017 Japanese guidelines for the management of community-acquired nonbacteremic pneumococcal pneumonia of the Japanese Respiratory Society (JRS). Setting Kobe university hospital, Japan. Methods A retrospective case series review including antibiotic use and length of hospital stay was conducted using the medical records from April 2008 to May 2019 at a university hospital in Japan. Main outcome measure Impact of antibiotic de-escalation therapy on the antibiotic costs. Results Among 55 patients who were eligible, the treating physicians de-escalated antibiotics in 28 (51%). The differences in the median length of hospital stay and the incidence of adverse drug reactions between the two groups were not statistically significant (p = 0.67 and 1.0, respectively). However, the median total antibiotic cost per infected patient in the de-escalated group was significantly lower than that in the non-de-escalated group [$269.8 ($195-$389) vs. $420.5 ($221-$799), p = 0.048]. Conclusion Antibiotic de-escalation based on the 2017 JRS guidelines leads to a reduction in total antibiotic costs for the management of community-acquired nonbacteremic pneumococcal pneumonia.
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13
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Ramos-Rincón JM, Fernández-Gil A, Merino E, Boix V, Gimeno A, Rodríguez-Diaz JC, Valero B, Sánchez-Martínez R, Portilla J. The quick Sepsis-related Organ Failure Assessment (qSOFA) is a good predictor of in-hospital mortality in very elderly patients with bloodstream infections: A retrospective observational study. Sci Rep 2019; 9:15075. [PMID: 31636319 PMCID: PMC6803690 DOI: 10.1038/s41598-019-51439-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Accepted: 10/01/2019] [Indexed: 01/09/2023] Open
Abstract
People over 80 years old are now the fastest-growing age group. Bloodstream infections (BSI) in these patients may present with specific characteristics. The objective of this study was to analyze independent factors affecting in-hospital mortality (IHM) due to BSI in very elderly patients (≥80 years of age) and to compare the clinical presentation of BSI in patients aged 80–89 years versus those aged 90 or more. Retrospective, cross-sectional and observational study of BSI in patients aged 80 years or older. The study used IHM as the primary outcome. Stepwise multiple logistic regression models were used to identify associations between potential predictors and IHM. Of the 336 included patients, 76.8% (n = 258) were in the 80–89-year age group and 23.2% (n = 78) in the 90+ age group; 17.3% (n = 58) of patients died during admission. This outcome was independently associated with quick Sepsis Related Organ Failure Assessment (qSOFA) of 2 or more (adjusted odds ratio [aOR] 4.7, 95% confidence interval [CI] 2.3–9.4; p < 0.001). Other predictors included an origin of BSI outside the urinary tract (aOR 5.5, 95% CI 2.4–12.6; p < 0.001), thrombocytopenia (aOR 4.9, 95% CI 1.8–13.4; p = 0.002), hospital-acquired infection (aOR 3.0, 95% CI 1.2–7.5; p = 0.015), and inappropriate empiric antibiotics (aOR 2.0, 95% CI 1.1–3.9; p = 0.04). IHM was 23.1% in the 90+ age group and 15.5% in patients aged 80 to 89 (p = 0.012). However, the 90+ age group was more likely to have a score of at least 2 on the qSOFA (29.9% vs. 19.1%, p = 0.043) and Pitt bacteremia scales (44.9% vs. 30.2%; p = 0.02), as well as chronic kidney disease (56.4% vs. 36.0%; p = 0.001) and altered mental state (40.3% vs. 25.7%; p = 0.013). In conclusion: A qSOFA score of 2 or more and a BSI originating outside the urinary tract were independent predictors of IHM. The 90+ age group was at higher risk than the 80–89-year age group of having a qSOFA score and Pitt bacteremia score of 2 or more as well as an altered mental state.
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Affiliation(s)
- José M Ramos-Rincón
- Department of Internal Medicine. General University Hospital of Alicante and Institute for Health and Biomedical Research of Alicante (ISABIAL- Foundation FISABIO), Alicante, Spain. .,Miguel Hernández University of Elche. San Joan d'Alacant Campus, Alicante, Spain.
| | - Adela Fernández-Gil
- Miguel Hernández University of Elche. San Joan d'Alacant Campus, Alicante, Spain
| | - Esperanza Merino
- Infectious Diseases Unit. General University Hospital of Alicante and Institute for Health and Biomedical Research of Alicante (ISABIAL- Foundation FISABIO), Alicante, Spain
| | - Vicente Boix
- Miguel Hernández University of Elche. San Joan d'Alacant Campus, Alicante, Spain.,Infectious Diseases Unit. General University Hospital of Alicante and Institute for Health and Biomedical Research of Alicante (ISABIAL- Foundation FISABIO), Alicante, Spain
| | - Adelina Gimeno
- Microbiology Service. General University Hospital of Alicante and Institute for Health and Biomedical Research of Alicante (ISABIAL- Foundation FISABIO), Alicante, Spain
| | - Juan C Rodríguez-Diaz
- Microbiology Service. General University Hospital of Alicante and Institute for Health and Biomedical Research of Alicante (ISABIAL- Foundation FISABIO), Alicante, Spain
| | - Beatriz Valero
- Department of Internal Medicine. General University Hospital of Alicante and Institute for Health and Biomedical Research of Alicante (ISABIAL- Foundation FISABIO), Alicante, Spain
| | - Rosario Sánchez-Martínez
- Department of Internal Medicine. General University Hospital of Alicante and Institute for Health and Biomedical Research of Alicante (ISABIAL- Foundation FISABIO), Alicante, Spain
| | - Joaquín Portilla
- Department of Internal Medicine. General University Hospital of Alicante and Institute for Health and Biomedical Research of Alicante (ISABIAL- Foundation FISABIO), Alicante, Spain.,Miguel Hernández University of Elche. San Joan d'Alacant Campus, Alicante, Spain.,Infectious Diseases Unit. General University Hospital of Alicante and Institute for Health and Biomedical Research of Alicante (ISABIAL- Foundation FISABIO), Alicante, Spain
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14
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Grudzinska FS, Aldridge K, Hughes S, Nightingale P, Parekh D, Bangash M, Dancer R, Patel J, Sapey E, Thickett DR, Dosanjh DP. Early identification of severe community-acquired pneumonia: a retrospective observational study. BMJ Open Respir Res 2019; 6:e000438. [PMID: 31258921 PMCID: PMC6561385 DOI: 10.1136/bmjresp-2019-000438] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2019] [Revised: 05/16/2019] [Accepted: 05/16/2019] [Indexed: 01/27/2023] Open
Abstract
Background Community-acquired pneumonia (CAP) is a leading cause of sepsis worldwide. Prompt identification of those at high risk of adverse outcomes improves survival by enabling early escalation of care. There are multiple severity assessment tools recommended for risk stratification; however, there is no consensus as to which tool should be used for those with CAP. We sought to assess whether pneumonia-specific, generic sepsis or early warning scores were most accurate at predicting adverse outcomes. Methods We performed a retrospective analysis of all cases of CAP admitted to a large, adult tertiary hospital in the UK between October 2014 and January 2016. All cases of CAP were eligible for inclusion and were reviewed by a senior respiratory physician to confirm the diagnosis. The association between the CURB65, Lac-CURB-65, quick Sequential (Sepsis-related) Organ Failure Assessment tool (qSOFA) score and National Early Warning Score (NEWS) at the time of admission and outcome measures including intensive care admission, length of hospital stay, in-hospital, 30-day, 90-day and 365-day all-cause mortality was assessed. Results 1545 cases were included with 30-day mortality of 19%. Increasing score was significantly associated with increased risk of poor outcomes for all four tools. Overall accuracy assessed by receiver operating characteristic curve analysis was significantly greater for the CURB65 and Lac-CURB-65 scores than qSOFA. At admission, a CURB65 ≥2, Lac-CURB-65 ≥moderate, qSOFA ≥2 and NEWS ≥medium identified 85.0%, 96.4%, 40.3% and 79.0% of those who died within 30 days, respectively. A Lac-CURB-65 ≥moderate had the highest negative predictive value: 95.6%. Conclusion All four scoring systems can stratify according to increasing risk in CAP; however, when a confident diagnosis of pneumonia can be made, these data support the use of pneumonia-specific tools rather than generic sepsis or early warning scores.
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Affiliation(s)
- Frances S Grudzinska
- Institute of Inflammation and Ageing, University of Birmingham College of Medical and Dental Sciences, Birmingham, UK
| | - Kerrie Aldridge
- Institute of Inflammation and Ageing, University of Birmingham College of Medical and Dental Sciences, Birmingham, UK
| | - Sian Hughes
- Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | | | - Dhruv Parekh
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
| | | | - Rachel Dancer
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
| | - Jaimin Patel
- Institute of Inflammation and Ageing, University of Birmingham College of Medical and Dental Sciences, Birmingham, UK
| | - Elizabeth Sapey
- Institute of Inflammation and Ageing, University of Birmingham College of Medical and Dental Sciences, Birmingham, UK
| | - David R Thickett
- Institute of Inflammation and Ageing, University of Birmingham College of Medical and Dental Sciences, Birmingham, UK
| | - Davinder P Dosanjh
- Institute of Inflammation and Ageing, University of Birmingham College of Medical and Dental Sciences, Birmingham, UK
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15
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Application of The Sepsis-3 Consensus Criteria in a Geriatric Acute Care Unit: A Prospective Study. J Clin Med 2019; 8:jcm8030359. [PMID: 30871231 PMCID: PMC6463250 DOI: 10.3390/jcm8030359] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2019] [Revised: 03/08/2019] [Accepted: 03/09/2019] [Indexed: 12/20/2022] Open
Abstract
The prognostic value of quick Sepsis-related Organ Failure Assessment (qSOFA) score in geriatric patients is uncertain. We aimed to compare qSOFA vs. Systemic Inflammatory Response Syndrome (SIRS) criteria for mortality prediction in older multimorbid subjects, admitted for suspected sepsis in a geriatric ward. We prospectively enrolled 272 patients (aged 83.7 ± 7.4). At admission, qSOFA and SIRS scores were calculated. Mortality was assessed during hospital stay and three months after discharge. The predictive capacity of qSOFA and SIRS was assessed by calculating the Area Under the Receiver Operating Characteristic Curve (AUROC), through pairwise AUROC comparison, and multivariable logistic regression analysis. Both qSOFA and SIRS exhibited a poor prognostic performance (AUROCs 0.676, 95% CI 0.609⁻0.738, and 0.626, 95% CI 0.558⁻0.691 for in-hospital mortality; 0.684, 95% CI 0.614⁻0.748, and 0.596, 95% CI 0.558⁻0.691 for pooled three-month mortality, respectively). The predictive capacity of qSOFA showed no difference to that of SIRS for in-hospital mortality (difference between AUROCs 0.05, 95% CI -0.05 to 0.14, p = 0.31), but was superior for pooled three-month mortality (difference between AUROCs 0.09, 95% CI 0.01⁻0.17, p = 0.029). Multivariable logistic regression analysis, accounting for possible confounders, including frailty, showed that both scores were not associated with in-hospital mortality, although qSOFA, unlike SIRS, was associated with pooled three-month mortality. In conclusion, neither qSOFA nor SIRS at admission were strong predictors of mortality in a geriatric acute-care setting. Traditional geriatric measures of frailty may be more useful for predicting adverse outcomes in this setting.
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Abstract
PURPOSE OF REVIEW To describe the current understanding and clinical applicability of severity scoring systems in pneumonia management. RECENT FINDINGS Severity scores in community-acquired pneumonia are strong markers of mortality, but are not necessarily clinical decision-aid tools. The use of severity scores to support outpatient care in low-risk patients has moderate-to-strong evidence available in the literature, mainly for the pneumonia severity index, and must be applied together with clinical judgment. It is not clear that severity scores are helpful to guide empiric antibiotic treatment. The inclusion of biomarkers and performance status might improve the predictive performance of the well known severity scores in community-acquired pneumonia. We should improve our methods for score evaluation and move toward the development of decision-aid tools. SUMMARY The application of the available evidence favors the use of severity scoring systems to improve the delivery of care for pneumonia patients. The incorporation of new methodologies and the formulation of different questions other than mortality prediction might help the further development of severity scoring systems, and enhance their support to the clinical decision-making process for the pneumonia-management cascade.
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17
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Lo RSL, Leung LY, Brabrand M, Yeung CY, Chan SY, Lam CCY, Hung KKC, Graham CA. qSOFA is a Poor Predictor of Short-Term Mortality in All Patients: A Systematic Review of 410,000 Patients. J Clin Med 2019; 8:jcm8010061. [PMID: 30626160 PMCID: PMC6351955 DOI: 10.3390/jcm8010061] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2018] [Revised: 12/28/2018] [Accepted: 01/02/2019] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND To determine the validity of the Quick Sepsis-Related Organ Failure Assessment (qSOFA) in the prediction of outcome (in-hospital and 1-month mortality, intensive care unit (ICU) admission, and hospital and ICU length of stay) in adult patients with or without suspected infections where qSOFA was calculated and reported; Methods: Cochrane Central of Controlled trials, EMBASE, BIOSIS, OVID MEDLINE, OVID Nursing Database, and the Joanna Briggs Institute EBP Database were the main databases searched. All studies published until 12 April 2018 were considered. All studies except case series, case reports, and conference abstracts were considered. Studies that included patients with neutropenic fever exclusively were excluded. RESULTS The median AUROC for in-hospital mortality (27 studies with 380,920 patients) was 0.68 (a range of 0.55 to 0.82). A meta-analysis of 377,623 subjects showed a polled AUROC of 0.68 (0.65 to 0.71); however, it also confirmed high heterogeneity among studies (I² = 98.8%, 95%CI 98.6 to 99.0). The median sensitivity and specificity for in-hospital mortality (24 studies with 118,051 patients) was 0.52 (range 0.16 to 0.98) and 0.81 (0.19 to 0.97), respectively. Median positive and negative predictive values were 0.2 (range 0.07 to 0.38) and 0.94 (0.85 to 0.99), respectively.
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Affiliation(s)
- Ronson S L Lo
- Accident and Emergency Medicine Academic Unit, Chinese University of Hong Kong, Hong Kong, China.
| | - Ling Yan Leung
- Accident and Emergency Medicine Academic Unit, Chinese University of Hong Kong, Hong Kong, China.
| | - Mikkel Brabrand
- Accident and Emergency Medicine Academic Unit, Chinese University of Hong Kong, Hong Kong, China.
- Department of Emergency Medicine, Hospital of South West Denmark, Finsensgade 35, DK-6700 Esbjerg, Denmark.
| | - Chun Yu Yeung
- Accident and Emergency Medicine Academic Unit, Chinese University of Hong Kong, Hong Kong, China.
| | - Suet Yi Chan
- Accident and Emergency Medicine Academic Unit, Chinese University of Hong Kong, Hong Kong, China.
| | - Cherry C Y Lam
- Accident and Emergency Medicine Academic Unit, Chinese University of Hong Kong, Hong Kong, China.
| | - Kevin K C Hung
- Accident and Emergency Medicine Academic Unit, Chinese University of Hong Kong, Hong Kong, China.
| | - Colin A Graham
- Accident and Emergency Medicine Academic Unit, Chinese University of Hong Kong, Hong Kong, China.
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18
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Noguchi S, Yatera K, Naito K, Hata R, Kawanami T, Yamasaki K, Kato T, Orihashi T, Inoue N, Sakamoto N, Yoshii C, Mukae H. Utility of the Quick Sequential Organ Failure Assessment in Japanese patients with nursing- and healthcare-associated pneumonia. Geriatr Gerontol Int 2018; 19:177-183. [PMID: 30556241 DOI: 10.1111/ggi.13581] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2018] [Revised: 09/21/2018] [Accepted: 10/28/2018] [Indexed: 11/26/2022]
Abstract
AIM To clarify the utility of sepsis evaluation using the Quick Sequential Organ Failure Assessment (qSOFA) tool in addition to the Pneumonia Severity Index (PSI); age, dehydration, respiration, orientation and blood pressure (A-DROP) index; and immunodeficiency, respiration, orientation, age and dehydration (I-ROAD) scoring systems, and risk factor evaluation of potentially drug-resistant (PDR) pathogens are suggested in the 2017 guidelines for pneumonia of the Japanese Respiratory Society in nursing- and healthcare-associated pneumonia patients. METHODS We included 289 hospitalized nursing- and healthcare-associated pneumonia patients between April 2016 and March 2017, and investigated the ability of PSI, A-DROP, I-ROAD and qSOFA to predict pneumonia-related mortality. We also evaluated the associations among the risk factors for PDR pathogens, the detection ratio of PDR pathogens and pneumonia-related mortality. RESULTS The mortality rate of pneumonia during hospitalization was 6.9% (20/289). The area under the curve for pneumonia-related mortality predicted using PSI, A-DROP, I-ROAD and qSOFA was 0.697 (95% confidence interval [CI] 0.59-0.80), 0.63 (95% CI 0.51-0.76), 0.61 (95% CI 0.52-0.70) and 0.701 (95% CI 0.59-0.81), respectively. In addition, higher areas under the curve were observed for pneumonia-related mortality predicted according to a combination of PSI and hypoalbuminemia (<2.5 g/dL) (0.75, 95% CI 0.64-0.86), and qSOFA and hypoalbuminemia (0.74, 95% CI 0.62-0.86) than for PSI and qSOFA alone. No significant associations were observed among the risk factors for PDR pathogens, the detection ratios of PDR pathogens and pneumonia-related mortality. CONCLUSIONS qSOFA and the combination of qSOFA and hypoalbuminemia might be simple and useful evaluation tools for predicting pneumonia-related mortality in nursing- and healthcare-associated pneumonia patients. Geriatr Gerontol Int 2019; 19: 177-183.
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Affiliation(s)
- Shingo Noguchi
- Department of Respiratory Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Kazuhiro Yatera
- Department of Respiratory Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Keisuke Naito
- Department of Respiratory Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Ryosuke Hata
- Department of Respiratory Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Toshinori Kawanami
- Department of Respiratory Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Kei Yamasaki
- Department of Respiratory Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Tatsuji Kato
- Department of Respiratory Medicine, Tobata Kyoritsu Hospital, Kitakyushu, Japan
| | - Takeshi Orihashi
- Department of Respiratory Medicine, Kitakyushu General Hospital, Kitakyushu, Japan
| | - Naoyuki Inoue
- Department of Internal Medicine, Kyushu Rosai Hospital, Kitakyushu, Japan
| | - Noriho Sakamoto
- Department of Respiratory Medicine, Unit of Translational Medicine, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Chiharu Yoshii
- Department of Respiratory Medicine, Wakamatsu Hospital of the University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Hiroshi Mukae
- Department of Respiratory Medicine, Unit of Translational Medicine, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
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19
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Jiang J, Yang J, Jin Y, Cao J, Lu Y. Role of qSOFA in predicting mortality of pneumonia: A systematic review and meta-analysis. Medicine (Baltimore) 2018; 97:e12634. [PMID: 30290639 PMCID: PMC6200542 DOI: 10.1097/md.0000000000012634] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Accepted: 09/10/2018] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND The concept of sepsis was redefined recently, and a new screening system termed the quick Sequential Organ Failure Assessment (qSOFA) was recommended for identifying infected patients at high risk for death. However, the predictive value of qSOFA for mortality in patients with pneumonia remains unclear. Thus, we performed a meta-analysis with the aim of determining the prognostic value of qSOFA in predicting mortality in patients with pneumonia. METHODS Embase, Google Scholar, and PubMed (up to March 2018) were searched for related articles. We constructed a 2 × 2 contingency table according to mortality and qSOFA scores (<2 and ≥2) in patients with pneumonia. Two investigators independently extracted data and assessed study eligibility. A bivariate meta-analysis model was used to determine the prognostic value of qSOFA in predicting mortality. I index and Q-test were used to assess heterogeneity. RESULTS Six studies with 17,868 patients were included. A qSOFA score ≥2 was related to a higher risk for death in patients with pneumonia, with a pooled risk ratio (RR) was 3.35 (95% CI, 2.24-5.01) using a random-effects model (I = 89.4%). The pooled sensitivity and specificity of a qSOFA score ≥2 to predict mortality in patients with pneumonia were 0.43 (95% CI, 0.33-0.53) and 0.86 (95% CI, 0.76-0.92), respectively. The diagnostic OR was 4 (95% CI, 3-6). The area under the summary receiver operator characteristic (SROC) curve was 0.67 (95% CI, 0.63-0.71). When we calculated the community-acquired pneumonia (CAP) subgroup, the pooled sensitivity and specificity were 0.36 (95% CI, 0.26-0.48) and 0.91 (95% CI, 0.84-0.95), respectively. The area under the SROC curve was 0.70 (95% CI, 0.66-0.74). CONCLUSIONS A qSOFA score ≥2 is strongly associated with mortality in patients with pneumonia, but the poor sensitivity of qSOFA may have limitations in the early identification of mortality in patients with pneumonia.
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Affiliation(s)
- Jianjun Jiang
- Department of Respiratory Medicine, The Second Affiliated Hospital of Anhui Medical University
| | - Jin Yang
- Department of Respiratory Medicine, The Second Affiliated Hospital of Anhui Medical University
| | - Yongmei Jin
- Department of Respiratory Medicine, The Second Affiliated Hospital of Anhui Medical University
| | - Jiyu Cao
- The Teaching Center for Preventive Medicine, School of Public Health, Anhui Medical University, Hefei, China
| | - Youjin Lu
- Department of Respiratory Medicine, The Second Affiliated Hospital of Anhui Medical University
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Müller M, Schefold JC, Guignard V, Exadaktylos AK, Pfortmueller CA. Hyponatraemia is independently associated with in-hospital mortality in patients with pneumonia. Eur J Intern Med 2018; 54:46-52. [PMID: 29657106 DOI: 10.1016/j.ejim.2018.04.008] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2017] [Revised: 03/13/2018] [Accepted: 04/08/2018] [Indexed: 12/14/2022]
Abstract
BACKGROUND Hyponatraemia on hospital admission has been shown to be a risk factor for illness severity in critically ill patients. The aim of the present study was to investigate whether hyponatraemia on emergency department (ED) admission independently influences in-hospital mortality, ICU admission, and/or length of hospitalisation in patients with pneumonia. METHODS 610 patients (64.4% male, median 66 years) diagnosed with pneumonia were identified by retrospective screening of electronic admission data (06/2011-06/2013). Patients were admitted to the ED of Bern University Hospital, Switzerland. Patient characteristics, potential confounders, and patient-centred clinical outcomes, including mortality, ICU admission, and length of hospitalisation, were analysed. Multivariate logistic analysis adjusted for typical confounders was performed to analyse the association of hyponatraemia with clinical outcomes. RESULTS In a large cohort of consecutive acutely admitted patients with pneumonia, the overall in-hospital mortality rate was 12.5%; 21.2% of patients required primary or secondary ICU admission, and the median length of hospital stay was 8 (IQR 5-13) days. At baseline, 47 patients (7.7%) were found to have concomitant hyponatraemia. Multivariate regression revealed a significant association between hyponatraemia and in-hospital mortality (adjusted OR: 2.7, 95% CI: 1.3-5.9, p = 0.010), but not with ICU admission (adjusted OR: 1.8, 95% CI: 0.9-3.6, p = 0.103) or length of hospitalisation (p = 0.493) after adjustment for age, neoplasia, COPD, suspected sepsis, and cardiac disease. The association was robust if controlled for other covariates, e.g. CRB-65 score. CONCLUSIONS Hyponatraemia on admission predicts poor outcome and is an independent risk factor for in-hospital mortality in admitted patients diagnosed with pneumonia.
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Affiliation(s)
- Martin Müller
- Department of Emergency Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
| | - Joerg C Schefold
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
| | - Viviane Guignard
- Department of Emergency Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Aristomenis K Exadaktylos
- Department of Emergency Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
| | - Carmen A Pfortmueller
- Department of Emergency Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland; Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
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Maitra S, Som A, Bhattacharjee S. Accuracy of quick Sequential Organ Failure Assessment (qSOFA) score and systemic inflammatory response syndrome (SIRS) criteria for predicting mortality in hospitalized patients with suspected infection: a meta-analysis of observational studies. Clin Microbiol Infect 2018; 24:1123-1129. [PMID: 29605565 DOI: 10.1016/j.cmi.2018.03.032] [Citation(s) in RCA: 74] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2018] [Revised: 03/13/2018] [Accepted: 03/20/2018] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To identify sensitivity, specificity and predictive accuracy of quick sequential organ failure assessment (qSOFA) score and systemic inflammatory response syndrome (SIRS) criteria to predict in-hospital mortality in hospitalized patients with suspected infection. METHODS This meta-analysis followed the Meta-analysis of Observational Studies in Epidemiology (MOOSE) group consensus statement for conducting and reporting the results of systematic review. PubMed and EMBASE were searched for the observational studies which reported predictive utility of qSOFA score for predicting mortality in patients with suspected or proven infection with the following search words: 'qSOFA', 'q-SOFA', 'quick-SOFA', 'Quick Sequential Organ Failure Assessment', 'quick SOFA'. Sensitivity, specificity, area under receiver operating characteristic (ROC) curves with 95% confidence interval (CI) of qSOFA and SIRS criteria for predicting in-hospital mortality was collected for each study and a 2 × 2 table was created for each study. RESULTS Data of 406 802 patients from 45 observational studies were included in this meta-analysis. Pooled sensitivity (95% CI) and specificity (95% CI) of qSOFA ≥2 for predicting mortality in patients who were not in an intensive care unit (ICU) was 0.48 (0.41-0.55) and 0.83 (0.78-0.87), respectively. Pooled sensitivity (95% CI) of qSOFA ≥2 for predicting mortality in patients (both ICU and non-ICU settings) with suspected infection was 0.56 (0.47-0.65) and pooled specificity (95% CI) was 0.78 (0.71-0.83). CONCLUSION qSOFA has been found to be a poorly sensitive predictive marker for in-hospital mortality in hospitalized patients with suspected infection. It is reasonable to recommend developing another scoring system with higher sensitivity to identify high-risk patients with infection.
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Affiliation(s)
- S Maitra
- Department of Anaesthesiology, Pain Medicine & Critical Care, All India Institute of Medical Sciences, New Delhi, India
| | - A Som
- Department of Anaesthesiology, MAMBS, Max Super Specialty Hospital, Saket, New Delhi, India.
| | - S Bhattacharjee
- Department of Anaesthesiology, Pain Medicine & Critical Care, All India Institute of Medical Sciences, New Delhi, India
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