The value of procalcitonin and the SAPS II and APACHE III scores in the differentiation of infectious and non-infectious fever in the ICU: a prospective, cohort study

Prevalence of Drug Fever among Cases of Nosocomial Fever: A Systematic Review and Meta-analysis

Objective Drug fever is defined as a fever that temporally coincides with the start of a culprit drug and disappears after discontinuation of the drug. It is a common cause of nosocomial fever, which refers to a fever that develops beyond the first 48 h after hospital admission. However, the exact prevalence of drug fever among cases of nosocomial fever is unclear, as is the variation in prevalence depending on the clinical setting and most common causative drugs. Methods PubMed MEDLINE, Dialog EMBASE, Cochrane Central Register of Controlled Trials, World Health Organization International Clinical Trials Registry Platform, and ClinicalTrials.gov were systematically searched. Studies that reported the prevalence of drug fever in patients with nosocomial fever were included. Two of the four reviewers conducted independent assessments of the inclusion, data extraction, and quality. Pooled adjusted odds ratios were generated using a random-effects model and presented with 95% confidence intervals (CIs). Results Fifteen meta-analysis from 15 studies were included. Ten studies did not report the definition of drug fever or excluded febrile patients who were admitted to the hospital within 24-48 h. The pooled prevalence of drug fever among cases of nosocomial fever was 3.0% (95% CI, 0.6-6.8%), which was largely consistent across the settings, except for at oriental medicine hospital. Only four studies reported the causative agents, and antibiotics were the most frequently reported. Conclusions The prevalence of drug fever is low in patients with nosocomial fever. Clinicians should recognize that drug fever is a diagnosis of exclusion, even in cases of nosocomial fever.

Metagenomic next-generation sequencing of plasma cell-free DNA improves the early diagnosis of suspected infections

BACKGROUND

Metagenomic next-generation sequencing (mNGS) could improve the diagnosed efficiency of pathogens in bloodstream infections or sepsis. Little is known about the clinical impact of mNGS test when used for the early diagnosis of suspected infections. Herein, our main objective was to assess the clinical efficacy of utilizing blood samples to perform mNGS for early diagnosis of suspected infections, as well as to evaluate its potential in guiding antimicrobial therapy decisions.

METHODS

In this study, 212 adult hospitalized patients who underwent blood mNGS test in the early stage of suspected infections were enrolled. Diagnostic efficacy of mNGS test and blood culture was compared, and the clinical impact of mNGS on clinical care was analyzed.

RESULTS

In our study, the total detection rate of blood mNGS was significantly higher than that of culture method (74.4% vs. 12.1%, P < 0.001) in the paired mNGS test and blood culture. Blood stream infection (107, 67.3%) comprised the largest component of all the diseases in our patients, and the detection rate of single blood sample subgroup was similar with that of multiple type of samples subgroup. Among the 187 patients complained with fever, there was no difference in the diagnostic efficacy of mNGS when blood specimens or additional other specimens were used in cases presenting only with fever. While, when patients had other symptoms except fever, the performance of mNGS was superior in cases with specimens of suspected infected sites and blood collected at the same time. Guided by mNGS results, therapeutic regimens for 70.3% cases (149/212) were changed, and the average hospitalized days were significantly shortened in cases with the earlier sampling time of admission.

CONCLUSION

In this study, we emphasized the importance of blood mNGS in early infectious patients with mild and non-specific symptoms. Blood mNGS can be used as a supplement to conventional laboratory examination, and should be performed as soon as possible to guide clinicians to perform appropriate anti-infection treatment timely and effectively. Additionally, combining the contemporaneous samples from suspected infection sites could improve disease diagnosis and prognoses. Further research needs to be better validated in large-scale clinical trials to optimize diagnostic protocol, and the cost-utility analysis should be performed.

Validation of APACHE II, APACHE III and SAPS II scores in in-hospital and one year mortality prediction in a mixed intensive care unit in Poland: a cohort study

BACKGROUND

There are several scores used for in-hospital mortality prediction in critical illness. Their application in a local scenario requires validation to ensure appropriate diagnostic accuracy. Moreover, their use in assessing post-discharge mortality in intensive care unit (ICU) survivors has not been extensively studied. We aimed to validate APACHE II, APACHE III and SAPS II scores in short- and long-term mortality prediction in a mixed adult ICU in Poland. APACHE II, APACHE III and SAPS II scores, with corresponding predicted mortality ratios, were calculated for 303 consecutive patients admitted to a 10-bed ICU in 2016. Short-term (in-hospital) and long-term (12-month post-discharge) mortality was assessed.

RESULTS

Median APACHE II, APACHE III and SAPS II scores were 19 (IQR 12-24), 67 (36.5-88) and 44 (27-56) points, with corresponding in-hospital mortality ratios of 25.8% (IQR 12.1-46.0), 18.5% (IQR 3.8-41.8) and 34.8% (IQR 7.9-59.8). Observed in-hospital mortality was 35.6%. Moreover, 12-month post-discharge mortality reached 17.4%. All the scores predicted in-hospital mortality (p < 0.05): APACHE II (AUC = 0.78; 95%CI 0.73-0.83), APACHE III (AUC = 0.79; 95%CI 0.74-0.84) and SAPS II (AUC = 0.79; 95%CI 0.74-0.84); as well as mortality after hospital discharge (p < 0.05): APACHE II (AUC = 0.71; 95%CI 0.64-0.78), APACHE III (AUC = 0.72; 95%CI 0.65-0.78) and SAPS II (AUC = 0.69; 95%CI 0.62-0.76), with no statistically significant difference between the scores (p > 0.05). The calibration of the scores was good.

CONCLUSIONS

All the scores are acceptable predictors of in-hospital mortality. In the case of post-discharge mortality, their diagnostic accuracy is lower and of borderline clinical relevance. Further studies are needed to create scores estimating the long-term prognosis of subjects successfully discharged from the ICU.

A Comparison of Acute Physiology and Chronic Health Evaluation III and Simplified Acute Physiology Score II in Predicting Sepsis Outcome in Intensive Care Unit

Context

Acute Physiology and Chronic Health Evaluation (APACHE) III and Simplified Acute Physiology Score (SAPS) II are frequently used to predict the outcome of Intensive Care Unit (ICU) patients of sepsis.

Aim

The aim of the study was to compare the predictability of outcome with APACHE III and SAPS II score in ICU patients of sepsis, severe sepsis, and septic shock and the 28-day mortality.

Settings and Design

This study was an observational, prospective cohort study.

Materials and Methods

A total of 100 consecutive patients of sepsis were studied over 20 months. The worst physiological and biochemical parameters during the first 24 h were recorded for the scores and the patient's 28-day outcome followed up.

Statistical Analysis Used

Continuous data were expressed as mean ± standard deviation or median. Receivers operating characteristic (ROC) curve was used to find the cutoff value, area under the curve, sensitivity and specificity of APACHE III score, and SAPS II score. Binary logistic regression with response variable as the outcome was utilized. P < 0.05 was considered statistically significant.

Results

The mean APACHE III score in the survivor group was 66.49 ± 18.56 as opposed to 80.67 ± 19.03 for nonsurvivors. The mean SAPS II score for the survivor group was 43.32 ± 13.02 as against the nonsurvivor group at 51.92 ± 12.34. The area under the ROC curve for APACHE III was 0.711 with 95% confidence interval as against 0.686 for SAPS II. The best cutoff value obtained for mortality prediction using the ROC curve was 69 for APACHE III while that for SAPS II was 49.

Conclusions

APACHE III was found to be a better predictor of mortality as compared to SAPS II though the margin of difference in mortality prediction was not high.

Nonspecific changes in clinical laboratory indicators in unselected terminally ill patients and a model to predict survival time based on a prospective observational study

BACKGROUND

The clinical prediction of survival is among the most challenging tasks because it refers to the process whereby the medical team assimilates clinical data using subjective methods. The purpose of this prospective observational study was to develop a model for evaluating survival time using objective laboratory parameters.

METHODS

Albumin (ALB), creatinine (CRE), C-reactive protein (CRP) and the neutrophilic leukocyte count (NEU) were measured using automated analysers. A total of 177 subjects with any one positive item of 4 items were included in the study. Age on the observation date and date of death were recorded.

RESULTS

ALB, CRE, CRP and the NEU were all significant predictors of survival time (p < 0.05). The median survival time of patients with anyone of the 4 items positive would be over 1 year; if any 2 items were positive, the median survival time was approximately 1 year; if any 3 items were positive, the median survival time was approximately 4 months and if 4 items were positive, the median survival time was approximately 20 days.

CONCLUSIONS

This study suggests that a model using ALB, CRE, CRP and the NEU is potentially useful in the objective evaluation of survival time in terminally ill patients.

Utility of Procalcitonin (PCT) and Mid regional pro-Adrenomedullin (MR-proADM) in risk stratification of critically ill febrile patients in Emergency Department (ED). A comparison with APACHE II score

BACKGROUND

The aim of our study was to evaluate the prognostic value of MR-proADM and PCT levels in febrile patients in the ED in comparison with a disease severity index score, the APACHE II score. We also evaluated the ability of MR-proADM and PCT to predict hospitalization.

METHODS

This was an observational, multicentric study. We enrolled 128 patients referred to the ED with high fever and a suspicion of severe infection such as sepsis, lower respiratory tract infections, urinary tract infections, gastrointestinal infections, soft tissue infections, central nervous system infections, or osteomyelitis. The APACHE II score was calculated for each patient.

RESULTS

MR-proADM median values in controls were 0.5 nmol/l as compared with 0.85 nmol/l in patients (P < 0.0001), while PCT values in controls were 0.06 ng/ml versus 0.56 ng/ml in patients (P < 0.0001). In all patients there was a statistically significant stepwise increase in MR-proADM levels in accordance with PCT values (P < 0.0001). MR-proADM and PCT levels were significantly increased in accordance with the Apache II quartiles (P < 0.0001 and P = 0.0012 respectively).In the respiratory infections, urinary infections, and sepsis-septic shock groups we found a correlation between the Apache II and MR-proADM respectively and MR-proADM and PCT respectively. We evaluated the ability of MR-proADM and PCT to predict hospitalization in patients admitted to our emergency departments complaining of fever. MR-proADM alone had an AUC of 0.694, while PCT alone had an AUC of 0.763. The combined use of PCT and MR-proADM instead showed an AUC of 0.79.

CONCLUSIONS

The present study highlights the way in which MR-proADM and PCT may be helpful to the febrile patient's care in the ED. Our data support the prognostic role of MR-proADM and PCT in that setting, as demonstrated by the correlation with the APACHE II score. The combined use of the two biomarkers can predict a subsequent hospitalization of febrile patients. The rational use of these two molecules could lead to several advantages, such as faster diagnosis, more accurate risk stratification, and optimization of the treatment, with consequent benefit to the patient and considerably reduced costs.