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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.
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.
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
The study aimed to investigate the predictive value of the quick sequential organ failure assessment (qSOFA) for clinical outcomes in emergency patients with community-acquired pneumonia (CAP).
A total of 742 CAP cases from the emergency department (ED) were enrolled in this study. The scoring systems including the qSOFA, SOFA and CURB-65 (confusion, urea, respiratory rate, blood pressure and age) were used to predict the prognostic outcomes of CAP in ICU-admission, acute respiratory distress syndrome (ARDS) and 28-day mortality. According to the area under the curve (AUC) of the receiver operating characteristic (ROC) curves, the accuracies of prediction of the scoring systems were analyzed among CAP patients.
The AUC values of the qSOFA, SOFA and CURB-65 scores for ICU-admission among CAP patients were 0.712 (95%CI: 0.678–0.745, P
Fei Zhou, Ting Yu, Ronghui Du, Guohui Fan, Ying Liu, Zhibo Liu, Jie Xiang, Yeming Wang, Bin Song, Xiaoying Gu, Lulu Guan, Yuan Wei, Hui Li, Xudong Wu, Jiuyang Xu, Shengjin Tu, Yi Zhang, Hua Chen, Bin Cao
The potential risk factors of older age, high SOFA score, and d-dimer greater than 1 μg/mL could help clinicians to identify patients with poor prognosis at an early stage. Prolonged viral shedding provides the rationale for a strategy of isolation of infected patients and optimal antiviral interventions in the future.
Chang, Y.-Y., Yang, Y.-S., Wu, S.-L., Wang, Y.-C., Chen, T.-L., on behalf of the ACTION study group, Lee, Y.-T.
Carbapenems are currently the preferred agents for the treatment of serious Acinetobacter infections. However, whether cefepime/cefpirome can be used to treat Acinetobacter bloodstream infection (BSI) if it is active against the causative pathogens is not clear. This study aimed to compare the efficacy of cefepime/cefpirome and carbapenem monotherapy in patients with Acinetobacter BSI. The population included 360 patients with monomicrobial Acinetobacter BSI receiving appropriate antimicrobial therapy admitted to four medical centres in Taiwan in 2012–2017. The predictors of 30-day mortality were determined by Cox regression analysis. The overall 30-day mortality rate in the appropriate antibiotic treatment group was 25.0% (90/360 patients), respectively. The crude 30-day mortality rates for cefepime/cefpirome and carbapenem therapy were 11.5% (7/61 patients) and 26.3% (21/80 patients), respectively. The patients receiving cefepime/cefpirome/carbapenem therapy were infected by Acinetobacter nosocomialis (51.8%), A. baumannii (18.4%) and A. pittii (12.1%). After adjusting for age, Sequential Organ Failure Assessment (SOFA) score, invasive procedures, and underlying diseases, cefepime/cefpirome therapy was not independently associated with a higher or lower 30-day mortality compared to the carbapenem therapy. SOFA score (hazard ratio [HR], 1.324; 95% confidence interval [CI], 1.137–1.543; P < 0.001) and neutropenia (HR, 7.060; 95% CI, 1.607–31.019; P = 0.010) were independent risk factors for 30-day mortality of patients receiving cefepime/cefpirome or carbapenem monotherapy. The incidence density of 30-day mortality for cefepime/cefpirome versus carbapenem therapy was 0.40% versus 1.04%. The therapeutic response of cefepime/cefpirome therapy was comparable to that of carbapenems among patients with Acinetobacter BSI receiving appropriate antimicrobial therapy.
Azevedo do Carmo T, Bonifácio Brige Ferreira I, Carvalho de Menezes R, et al.
AbstractBackgroundSeverity stratification scores developed in Intensive Care Units (ICUs) are used in interventional studies to identify the most critically ill. Studies that evaluate accuracy of these scores in ICU patients admitted with pneumonia are lacking. This study aims to determine performance of severity scores as predictors of mortality in critically ill patients admitted with pneumonia.MethodsProspective cohort study in a general ICU in Brazil. ICU severity scores (SAPS 3 and qSOFA), prognostic scores of pneumonia (CURB-65 and CRB-65), clinical and epidemiological variables in the first 6 hours of hospitalization were analyzed.ResultsA total of 200 patients were included between August 2015 and July 2018 with a median age of 81 years (IQR 67-90) and female predominance (52%) primarily admitted from the emergency department (65%) with community acquired pneumonia (80.5%). Poor discriminative performance in predicting mortality was found with SAPS 3, CURB-65, CRB-65 and qSOFA. Multivariate regression identified variables independently associated with mortality that were used to develop a novel pneumonia specific ICU severity score (Pneumonia SHOCK score) that outperformed SAPS3, CURB-65 and CRB-65 (AUC 0.80 vs 0.74, 0.65 and 0.63, respectively). Discriminate function of the Pneumonia SHOCK score was validated in an external multi-center cohort of critically ill patients admitted with community acquired pneumonia (AUC 0.81).ConclusionsWe created a parsimonious score system that accurately identifies elderly and non-elderly patients with pneumonia at highest risk of ICU death. These findings are critical to accurately stratify patients with severe pneumonia in therapeutic trials that aim to reduce pneumonia mortality.
Lind M, Phipps A, Mooney S, et al.
AbstractBackgroundSepsis, a life-threatening immunological response to an infection, disproportionality affects allogeneic hematopoietic cell transplant (HCT) recipients and is challenging to define. Clinical criteria that predict mortality and intensive care unit endpoints in patients with suspected infections (SI) have been adopted in sepsis definitions, but their predictive value among immunocompromised populations is largely unknown. Here, we evaluate three criteria among allogeneic HCT recipients.MethodsWe evaluated Systemic Inflammatory Response Syndrome (SIRS), quick-Sequential Organ Failure Assessment (qSOFA), and National Early Warning Score (NEWS) criteria in relation to short-term mortality among HCT recipients with SIs. Data from the first 100-days post-transplant were analyzed for patients transplanted between September 2010 - July 2017. We used the following cut-points (qSOFA/SIRS: 2+; NEWS: 7+) and restricted to first SI per hospital encounter.ResultsOf the 880 HCT recipients who experienced ≥ 1 SI, 58 (6.6%) died within 28 days and 22 (2.5%) within 10 days of a SI. In relation to 10-day mortality, SIRS was the most sensitive: 91.3% (95% CI:72.0 – 98.9%) but least specific: 35.0% (32.6 – 37.5%) whereas qSOFA was the most specific: 90.5% (88.9 – 91.9%) but least sensitive: 47.8% (26.8 – 69.4%). NEWS was moderately sensitive 78.3% (56.3 – 92.5%) and specific 70.2% (67.8 – 72.4%).ConclusionNEWS outperformed qSOFA and SIRS, but all three criteria had low to moderate predictive accuracy and the magnitude of the known predictive limitations of qSOFA and SIRS were at least as large as in general populations. Our data suggest that population-specific sepsis criteria are needed for immunocompromised patients.
Rehberg S, Morelli A, Jansen G.
To the Editor Compared with placebo, the nonadrenergic vasopressor angiotensin II was shown to increase mean arterial pressure after 3 hours in patients with vasodilatory shock in the Angiotensin II for the Treatment of High-Output Shock (ATHOS-3) trial (primary end point). In addition, angiotensin II also reached the secondary goal of a greater reduction in the cardiovascular Sequential Organ Failure Assessment (SOFA) score after 48 hours vs placebo. As a consequence, research with angiotensin II continued and it was approved by the US Food and Drug Administration.
Cohen I, Mello MM.
In Reply We agree with Mr Kels that HIPAA has involved burdens for physicians—some real and others amplified by uncertainty and fear of liability. However, Kels misread our Viewpoint insofar as he suggests that we are arguing for a private right of action to increase physicians’ liability under HIPAA. Such a move would do little to help regulate many uses of health data by technology companies because they fall outside HIPAA’s scope.
In the Preliminary Communication entitled “Effect of Vitamin C Infusion on Organ Failure and Biomarkers of Inflammation and Vascular Injury in Patients With Sepsis and Severe Acute Respiratory Failure: The CITRIS-ALI Randomized Clinical Trial” published in the October 1, 2019, issue of JAMA, data in Table 1 for vasopressor use and mSOFA scores were incorrect. In addition, a unit of measure was incorrectly added to an mSOFA score in the legend to Figure 2. This article has been corrected online.
Carrie, C., Delzor, F., Roure, S., Dubuisson, V., Petit, L., Molimard, M., Breilh, D., Biais, M.
OBJECTIVE: To assess the appropriateness of recommended regimens for empirical MIC coverage in critically ill patients with open abdomen and negative pressure therapy (OA/NPT).METHODS: Over a 5-year period, every critically ill patient who received amikacin and who underwent therapeutic drug monitoring (TDM) while treated by OA/NPT was retrospectively included. A population PK modelling was performed considering the effect of ten covariates (age, sex, TBW, ABW, BSA, modified SOFA score, vasopressor use, CLCr, fluid balance and amount of fluids collected by the NPT over the sampling day) in patients who underwent or not continuous renal replacement therapy (CRRT). Monte Carlo simulations were employed to determine the fractional target attainment (FTA) for the PK/PD targets (Cmax/MIC ratio ≥ 8 and AUC0-24h/MIC ≥ 75).RESULTS: Seventy critically ill patients treated by OA/NPT (contributing for 179 concentration values) were included. Amikacin PK concentrations were best described by a two-compartment model with linear elimination and proportional residual error, with CLCR and ABW as significant covariates for Vd and CLCR for CL. The reported volume of distribution (Vd) in non-CRRT and CRRT patients was 35.8 and 40.2 L respectively. In Monte Carlo simulations, ABW-adjusted doses between 25 and 35 mg/kg were needed to reach an FTA > 85% for various renal functions.CONCLUSION: Despite an increased Vd and a wide inter-individual variability, desirable PK/PD targets may be achieved using an ABW-pondered loading dose of 25 - 30 mg/kg. When targeting less susceptible pathogens, higher dosing regimens are probably needed in ARC patients. Further studies are needed to assess the effect of OA/NPT in PK parameters of antimicrobial agents.
Gong Y, Yan X, Sun X, et al.
AbstractBackgroundOncostatin-M (OSM) is a pleiotropic cytokine of the IL-6 family. The role of OSM in sepsis remains unknown.MethodsSerum OSM level was determined and analyzed in septic patients on day of intensive care unit (ICU) admission. Furthermore, the effects of OSM on polymicrobial sepsis induced by cecal ligation and puncture (CLP) were assessed.ResultsOn day of ICU admission, septic patients had significantly higher serum OSM levels when compared with ICU patient controls and healthy volunteers, which were related to the severity of sepsis, including parameters such as the Sequential [Sepsis-related] Organ Failure Assessment (SOFA) score, procalcitonin (PCT) level, and white blood cell (WBC) number. A high serum OSM level on ICU admission was associated with 28-day mortality in septic patients. In CLP-induced polymicrobial sepsis, anti-OSM antibody decreased tissue inflammation and injury, and thus improved survival, while local and systemic bacterial dissemination was almost constant. Complementarily, supplementation with recombinant OSM protein in septic mice increased tissue injury, amplified inflammation, and worsened mortality after CLP, while it did not affect bacterial dissemination in septic mice.ConclusionsSepsis results in an increased production of OSM, which might be a potential prognostic biomarker and therapeutic target for sepsis.
Tsolaki, V., Mantzarlis, K., Mpakalis, A., Malli, E., Tsimpoukas, F., Tsirogianni, A., Papagiannitsis, K., Zygoulis, P., Papadonta, M.-E., Petinaki, E., Makris, D., Zakynthinos, E.
Data on the effectiveness of ceftazidime-avibactam (CAZ-AVI) in critically ill, mechanically ventilated patients are limited. The present retrospective observational cohort study, which was conducted in two general Intensive Care Units (ICUs) in central Greece, compared critically-ill, mechanically ventilated patients suffering from carbapenem-resistant enterobacteriaceae (CRE) infections receiving CAZ-AVI to patients who received appropriate available antibiotic therapy. Clinical, microbiological outcomes and safety issues were evaluated. A secondary analysis in patients with blood stream infections (BSI) was conducted. Forty-one patients that received CAZ-AVI (CAZ-AVI group) were compared to thirty-six patients receiving antibiotics other than CAZ-AVI (control group). There was significant improvement in the SOFA score on Day 4 and 10 in the CAZ-AVI compared to the control group (p=0.006, and p=0.003 respectively). Microbiological eradication was accomplished in 33/35 (94.3%) in CAZ-AVI group vs 21/31 (67.7%) patients in control group (p=0.021) and clinical cure was observed in 33/41 (80.5%) vs 19/36 (52.8%) patients (p=0.010), respectively. The results were similar in BSI subgroups for both outcomes (p=0.038 and p=0.014, respectively). 28-day survival was 85.4% in the CAZ-AVI and 61.1% in the control group (log Rank=0.035), while there were 2 and 12 relapses in each group (p=0.042). A CAZ-AVI containing regime was independent predictor of survival and clinical cure (OR 5.575, p=0.012 and OR 5.125, p=0.004, respectively) along with illness severity. In conclusion, no significant side effects were reported. A CAZ-AVI containing regime is more effective than other available antibiotic agents for the treatment of CRE infections in the high-risk, mechanically-ventilated, ICU population.
Ymkje Stienstra, Dorien T Beeres, Richard Phillips, Machiel Vonk, Sofanne J Ravensbergen
We read the Article by David Engelman and colleagues1 with interest. Their overview of the key operational research questions to develop a global control programme for scabies provides a clear research agenda for the years to come.1 Mass drug administration (MDA) using ivermectin reduced the prevalence of both scabies and impetigo tremendously in Fiji with a sustained effect even 24 months after the intervention.2 Future studies should prioritise the inclusion of non-island populations.
The sepsis-induced immunodepression contributes to impaired clinical outcomes of various stress conditions. This syndrome is well documented and characterized by attenuated function of innate and adaptive immune cells. Several pharmacological interventions aimed to restore the immune response are emerging of which interferon-gamma (IFNγ) is one. It is of paramount relevance to obtain clinical information on optimal timing of the IFNγ-treatment, −tolerance, −effectiveness and outcome before performing a RCT. We describe the effects of IFNγ in a cohort of 18 adult and 2 pediatric sepsis patients.
In this open-label prospective multi-center case-series, IFNγ treatment was initiated in patients selected on clinical and immunological criteria early ( 7 days) following the onset of sepsis. The data collected in 18 adults and 2 liver transplanted pediatric patients were: clinical scores, monocyte expression of HLA-DR (flow cytometry), lymphocyte immune-phenotyping (flow cytometry), IL-6 and IL-10 plasma levels (ELISA), bacterial cultures, disease severity, and mortality.
In 15 out of 18 patients IFNγ treatment was associated with an increase of median HLA-DR expression from 2666 [IQ 1547; 4991] to 12,451 [IQ 4166; 19,707], while the absolute number of lymphocyte subpopulations were not affected, except for the decrease number of NK cells 94.5 [23; 136] to 32.5 [13; 90.8] (0.0625)]. Plasma levels of IL-6 464 [201–770] to 108 (89–140) ng/mL (p = 0.04) and IL-10 from IL-10 from 29 [12–59] to 9 [1–15] pg/mL decreased significantly. Three patients who received IFNγ early after ICU admission (
Fei Peng, Wei Chang, Chun Pan, Yi Yang
We appreciated the comments by Dr van Oers and colleagues concerning the effect of PCT-guided cessation of antibiotics in patients with the SOFA score less than 8. Our meta-analysis revealed that PCT-guided cessation of antibiotic therapy decreased the short-term mortality in patients with an average SOFA score < 8, suspected sepsis or lower algorithm adherence (< 70%), but not in those with a score > 8, confirmed sepsis or higher adherence(Peng et al., 2019). Compared to the standard care group, PCT-guided antibiotic therapy failed to decrease the mortality or shorten the ICU length of stay, as previous trials reported(Bouadma et al., 2010; Jensen et al., 2011; Bloos et al., 2016).
Jos A.H. van Oers, Maarten W Nijsten, Evelien de Jong, Albertus Beishuizen, Dylan W de Lange
John F. McNamara, Patrick NA. Harris, Mark D. Chatfield, Penelope Lorenc, David L. Paterson
To evaluate the sequential organ failure assessment (SOFA), modified SOFA scoring and a novel performance score based on the Karnofsky score for measuring outcome following a bloodstream infection.
Intravenous (IV) zanamivir could be a suitable alternative for the treatment of severe influenza A(H1N1)pdm09 infection in patients who are unable to take oral or inhaled medication, for example, those on mechanical ventilation and extracorporeal membrane oxygenation (ECMO). However, data on the clinical outcomes of such patients is limited.
We report the clinical outcomes of four patients who were admitted at the intensive care unit during the 2017–2018 influenza season with severe sepsis (SOFA score > 11) and acute respiratory distress syndrome requiring ECMO and mechanical ventilation. Two patients were immune-compromised. The A(H1N1)pdm09 genome was confirmed by polymerase chain reaction (PCR) on nasopharyngeal specimen swabs prior to administration of IV zanamivir at a dose of 600 mg twice daily. Weekly qualitative PCR analysis was done to monitor viral clearance, with zanamivir treatment being discontinued upon receipt of negative results. In addition, the patients were managed for concomitant multidrug-resistant bacterial infections, with infection resolution confirmed with blood cultures.
The median time for zanamivir treatment was 10 days (IQR 10–17). The clinical outcome was favourable with all four patients surviving and improving clinically. All four patients achieved viral clearance of A(H1N1)pdm09 genome, and resolution of multidrug-resistant bacterial infections.
IV zanamivir could be a good therapeutic option in patients with severe influenza A(H1N1)pdm09 infection who are unable to take oral or aerosolised antiviral medication. We recommend prospective randomized control trials to support this hypothesis.
Emily Herrett, Sarah Gadd, Rod Jackson, Krishnan Bhaskaran, Elizabeth Williamson, Tjeerd van Staa, Reecha Sofat, Adam Timmis, Liam Smeeth
A cardiovascular risk-based strategy (QRISK2 ≥10%) could prevent over a third more cardiovascular disease events than the 2011 NICE guideline and a fifth more than the 2019 NICE guideline, with similar efficiency regarding number treated per event avoided.
Hiemstra, Bart; Eck, Ruben J.; Wiersema, Renske; Kaufmann, Thomas; Koster, Geert; Scheeren, Thomas W.L.; Snieder, Harold; Perner, Anders; Pettilä, Ville; Wetterslev, Jørn; Keus, Frederik; van der Horst, Iwan C.C.; SICS Study Group
Caregivers use clinical examination to timely recognize deterioration of a patient, yet data on the prognostic value of clinical examination are inconsistent. In the Simple Intensive Care Studies-I, we evaluated the association of clinical examination findings with 90-day mortality in critically ill patients.
Prospective single-center cohort study.
ICU of a single tertiary care level hospital between March 27, 2015, and July 22, 2017.
All consecutive adults acutely admitted to the ICU and expected to stay for at least 24 hours.
A protocolized clinical examination of 19 clinical signs conducted within 24 hours of admission.
Independent predictors of 90-day mortality were identified using multivariable logistic regression analyses. Model performance was compared with established prognostic risk scores using area under the receiver operating characteristic curves (AUC). Robustness of our findings was tested by internal bootstrap validation and adjustment of the threshold for statistical significance.
A total of 1,075 patients were included, of whom 298 patients (28%) had died at 90-day follow-up. Multivariable analyses adjusted for age and norepinephrine infusion rate demonstrated that the combination of higher respiratory rate, higher systolic blood pressure, lower central temperature, altered consciousness, and decreased urine output was independently associated with 90-day mortality (AUC = 0.74; 95% CI, 0.71–0.78). Clinical examination had a similar discriminative value as compared with the Simplified Acute Physiology Score-II (SAPS-II) (AUC = 0.76; 95% CI, 0.73–0.79; p = 0.29) and Acute Physiology and Chronic Health Evaluation-IV (APACHE-IV) (AUC = 0.77; 95% CI, 0.74–0.80; p = 0.16) and was significantly better than the Sequential Organ Failure Assessment (SOFA) (AUC = 0.67; 95% CI, 0.64–0.71; p < 0.001).
Clinical examination has reasonable discriminative value for assessing 90-day mortality in acutely admitted ICU patients. In our study population, a single, protocolized clinical examination had similar prognostic abilities compared with the SAPS-II and APACHE-IV and outperformed the SOFA score.
New affiliation for Dr. Eck: Department of Internal Medicine, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.
Drs. Hiemstra, van der Horst, and Keus drafted the manuscript and conducted the analyses. Drs. van der Horst and Keus created the idea of the study. Drs. Eck and Koster developed the protocol and implemented the study. Mr. Wiersema and Dr. Kaufmann contributed substantially to the data collection. Drs. Wetterslev and Snieder contributed to the statistical analyses and design of the detailed statistical analyses plan. Professors Scheeren, Perner, and Pettilä critically reviewed the article. All authors critically reviewed the article and agreed with the final version and findings.
Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (http://journals.lww.com/ccmjournal).
Prof dr. Scheeren received research funding and honoraria from Edwards Lifesciences and Masimo Inc. (Irvine, CA) for consulting and lecturing and from Pulsion Medical Systems SE for lecturing in the past. The remaining authors have disclosed that they do not have any potential conflicts of interest.
Ethics approval: Medisch Ethische Toetsingscommissie, University Medical Center Groningen; METc M15.168207.
ORCID IDs: Dr. Hiemstra: 0000-0001-6547-2138; Dr. Eck: 0000-0001-7440-2465; Mr. Wiersema: 0000-0003-2413-2852; Dr. Kaufmann: 0000-0003-0589-8879; Dr. Koster: 0000-0002-8927-3077; Dr. Scheeren: 0000-0002-9184-4190; Dr. Snieder; 0000-0003-1949-2298; Dr. Perner: 0000-0002-4668-0123; Dr. Wetterslev: 0000-0001-7778-1771; Dr. Keus: 0000-0003-1516-1475; Dr. van der Horst: 0000-0003-3891-8522.
For information regarding this article, E-mail: firstname.lastname@example.org
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Copyright © by 2019 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.
This study aimed to determine the prevalence of infectious diseases and risk factors for one-year mortality in elderly emergency department (ED) patients.
A retrospective cohort study of patients aged 65 and over who visited the ED of one urban teaching hospital in Bangkok, Thailand and who were diagnosed with infectious diseases between 1 January 2016 and 30 June 2016.
There were 463 elderly patients who visited ED with infectious diseases, accounting for 14.5% (463/3,196) of all elderly patients’ visits. The most common diseases diagnosed by emergency physicians (EPs) were pneumonia [151 (32.6%) patients] followed by pyelonephritis [107 (23.1%) patients] and intestinal infection [53 (11.4%) patients]. Moreover, 286 (61.8%) patients were admitted during the study period. The in-hospital mortality rate was 22.7%. 181 (39.1%) patients died within 1 year. Our multivariate analysis showed that age 85 years and older [odds ratio (OR) = 1.89; 95% confidence interval (CI): 1.36–2.63], Charlson Co-morbidity Index score ≥ 5 (OR = 3.51; 95% CI2.14–5.77), lactate ≥4 mmol/l (OR = 2.66;95% CI 1.32–5.38), quick Sequential Organ Failure Assessment (qSOFA) score ≥ 2 (OR = 5.46; 95% CI 2.94–10.12), and platelet count
Challener DW, Prokop LJ, Abu-Saleh O.
This Viewpoint charts the rise in publications describing risk prediction tools, such as the FRAX, CHADS2, and SOFA scores, and discusses the implications of using algorithms for clinical decisions in the absence of evidence about the effects of the tools on patient care and outcomes.
Kan F, Tan C, von Bahr Greenwood T, et al.
AbstractBackgroundGlobally approximately 500,000 people with severe dengue (SD) require hospitalization yearly; about 12,500 (2.5%) die. Secondary hemophagocytic lymphohistiocytosis (sHLH) is a potentially fatal hyperinflammatory condition for which HLH-directed therapy (as etoposide and dexamethasone) can be life-saving. Prompted by the high mortality in SD and the increasing awareness that patients with SD may develop sHLH, our objectives were to i) determine the frequency of dengue-HLH in SD, ii) describe clinical features of dengue-HLH, iii) assess mortality rate in SD and dengue-HLH, and iv). identify mortality-associated risk factors in SD.MethodsA 5-year retrospective single-center study on all adult patients with SD admitted to a tertiary ICU in Malaysia.ResultsThirty-nine/180 (22%) patients with SD died. Twenty-one/180 (12%) had HLH defined as HLH-probability ≥70% according to HScore; nine (43%) died. Similarly, 12/31 (39%) fulfilling ≥4 and 7/9 (78%) fulfilling ≥5 HLH-2004 diagnostic criteria died. Peak values of AST, ALT, LDH, and creatinine correlated to fatality (OR=2.9, 3.4, 5.8, and 31.9; all p
Richard-Greenblatt M, Boillat-Blanco N, Zhong K, et al.
AbstractBackgroundThe inability to identify individuals with acute fever at risk of death is a barrier to effective triage and management of severe infections, especially in low-resource settings. Since endothelial and immune activation contribute to the pathogenesis of various distinct life-threatening infections, we hypothesized that measuring mediators of these pathways at clinical presentation would identify febrile adults at risk of death.MethodsPlasma concentrations of markers of endothelial (Angpt-2, sFlt-1, sVCAM-1, sICAM-1) and immune (sTREM-1, IL-6, IL-8, CHI3L1, sTNFR1, PCT, CRP) activation pathways were determined in consecutive adults with acute fever (>38°C) at presentation to outpatient clinics in Dar es Salaam, Tanzania. We evaluated the accuracy of these mediators in predicting all-cause mortality, and examined whether markers could improve the prognostic accuracy of clinical scoring systems, including the quick Sequential Organ Failure Assessment (qSOFA) and Glasgow Coma Scale (GCS).ResultsOf 507 febrile adults, 32 died (6.3%) within 28 days of presentation. sTREM-1 was the best prognostic marker for 28-day mortality (area under the receiver operating characteristic [AUROC] 0.87, 95% CI 0.81-0.92) and was significantly better than CRP (P
Satoshi Koyama, Yutaka Yamaguchi, Koichiro Gibo, Izumi Nakayama, Shinichiro Ueda
by Satoshi Koyama, Yutaka Yamaguchi, Koichiro Gibo, Izumi Nakayama, Shinichiro Ueda
Background The quick sequential organ failure assessment (qSOFA) score has recently been introduced to the emergency department (ED) and wards, and it predicted a higher number of deaths among patients with sepsis compared with baseline risk. However, studies about the application of the qSOFA score are limited in prehospital settings. Thus, this study aimed to assess the performance of prehospital qSOFA score in predicting the risk of mortality among patients with infection. Methods This single center, retrospective cohort study was conducted in a Japanese tertiary care teaching hospital between April 2016 and March 2017. We enrolled all consecutive adult patients transported to the hospital by ambulance and admitted to the ED due to a suspected infection. We calculated the prehospital qSOFA score using the first vital sign obtained at the scene by emergency medical service (EMS) providers. The primary outcome was in-hospital mortality. The Cox proportional hazards model was used to assess the association between prehospital qSOFA positivity and in-hospital mortality. Results Among the 925 patients admitted to the ED due to a suspected infection, 51.1% (473/925) were prehospital qSOFA-positive and 48.9% (452/925) were prehospital qSOFA-negative. The in-hospital mortality rates were 14.0% (66/473) in prehospital qSOFA-positive patients and 6.0% (27/452) in prehospital qSOFA-negative patients. The Cox proportional hazard regression model revealed a strong association between prehospital qSOFA score and in-hospital mortality (adjusted hazard ratio: 2.41, 95% confidence interval: 1.51–3.98; p
Nobuhiro Asai, Hiroki Watanabe, Arufumi Shiota, Hideo Kato, Daisuke Sakanashi, Mao Hagihara, Yusuke Koizumi, Yuka Yamagishi, Hiroyuki Suematsu, Hiroshige Mikamo
In Mozambique, the prevalence of malaria in children under 5 years of age is among the highest in the world, but limited data exist on determinants of care-seeking behaviour for malaria. This study aimed at determining the trends and factors associated with care-seeking behaviour for fever among children under 5 years of age and to assess the treatment practices for malaria.
Secondary data analysis of two cross-sectional studies. Descriptive statistics were used to summarize socio-economic and demographic characteristics of participants, using data from the 2011 Demographic and Health Survey and 2015 Indicators of Immunization, Malaria and HIV/AIDS Survey. Complex sampling logistic regression model was used to identify factors associated with care-seeking behaviour, with estimated adjusted odds ratio and respective 95% confidence intervals, only for 2015 IMASIDA data.
A total of 10,452 and 5168 children under 5 years of age were enrolled in the 2011 DHS and 2015 IMASIDA, respectively. Care-seeking for fever in public and private sectors remained stable during this period (62.6%; 835/1432 in 2011 and 63.7%; 974/1529 in 2015). The main place where care was sought in both surveys was public hospitals (86.2%; 773/897 in 2011 and 86.7%; 844/974 in 2015). Prescription of anti-malarial drugs increased from 42.9% (385/897) in 2011 to 53.8% (524/974) in 2015. Artemether–lumefantrine was the most used anti-malarial drug for febrile children in both surveys and its use increased from 59.0% (219/373) in 2011 to 89.3% (457/512) in 2015. Data from 2015 elucidated that care-seeking was more common in children whose mothers had a secondary level of education (AOR = 2.27 [95% CI 1.15–4.49]) and among those in poorer quintile (AOR = 1.46 [95% CI 0.83–1.90]). Mothers with higher education level (AOR = 0.16 [95% CI 0.34–0.78]) were less likely to seek out care. People from Manica (AOR = 2.49 [1.03–6.01]), Sofala ([AOR = 2.91 [1.03–8.24]), Inhambane (AOR = 3.95 [1.25–12.45]), Gaza (AOR = 3.25 [1.22–8.65]) and Maputo Province (AOR = 2.65 [1.10–6.41]) were more likely to seek care than people from Maputo City.
Data from this study showed that care-seeking in Mozambique remained suboptimal. Interventions to raise the awareness for early care-seeking during episodes of fever should be urgently reinforced and intensified.
The prognostic capability of the quick Sequential Organ Failure Assessment (qSOFA) bedside scoring tool is uncertain in non-ICU patients with sepsis due to bacteremia given the low number of patients previously evaluated.
We performed a retrospective cohort study of adult hospitalized patients with Staphylococcus aureus bacteremia (SAB). Medical charts were reviewed to determine qSOFA score, systemic inflammatory response syndrome (SIRS) criteria, and Pitt bacteremia score (PBS) at initial presentation; their predictive values were compared for ICU admission within 48 h, ICU stay duration > 72 h, and 30-day mortality.
Four hundred twenty-two patients were included; 22% had qSOFA score ≥2. Overall, mean age was 56y and 75% were male. More patients with qSOFA ≥2 had altered mentation (23% vs 5%, p
In the new Sepsis-3 definition, sepsis is defined as “life-threatening organ dysfunction due to a dysregulated host response to infection.” We tested the predictive validity of the systematic inflammatory response syndrome (SIRS) criteria in patients in the Sepsis-3 cohort.
Among 1243 electronic health records from 1 January to 31 December 2015 at Sichuan University West China Hospital, we identified patients with sepsis and septic shock according to the Sepsis-3 definition and divided them into 2 subsets: SIRS-positive and SIRS-negative. We compared their characteristics and outcomes as well as the predictive validity of the SIRS criteria for in-hospital mortality.
Of the 1243 patients, 631 were enrolled. Among these, 538 (85.3%) patients had SIRS-positive sepsis or septic shock, 168 (31.2%) of whom died, and 93 (14.7%) had SIRS-negative sepsis or septic shock, 20 (21.5%) of whom died (p = 0.06). Over a 1-year period, these groups had similar characteristics and changes in mortality. Among patients of the Sepsis-3 cohort admitted to the intensive care unit, the predictive validity for in-hospital mortality was lower for the SIRS criteria (area under the receiver operating characteristic curve [AUROC], 0.53; 95% confidence interval [95% CI], 0.49–0.57) than for the sequential (sepsis-related) organ failure assessment (SOFA) criteria (AUROC, 0.70; 95% CI, 0.66–0.74; p ≤ 0.01 for both). The SIRS score had poor predictive validity for the risk of in-hospital mortality.
In this cohort study of the new Sepsis-3 definition, we found that the SIRS criteria are weaker than the SOFA criteria with respect to their predictive efficacy for in-hospital death.
This retrospective cohort study derived a “quick” version of the Pitt bacteremia score (qPitt) using binary variables in patients with Gram-negative bloodstream infections (BSI). The qPitt discrimination was then compared to quick sepsis-related organ failure assessment (qSOFA) and systemic inflammatory response syndrome (SIRS).
Hospitalized adults with Gram-negative BSI at Palmetto Health hospitals in Columbia, SC, USA from 2010 to 2013 were identified. Multivariate Cox proportional hazards regression was used to determine variables associated with 14-day mortality.
Among 832 patients with Gram-negative BSI, median age was 65 years and 449 (54%) were women. After adjustments for age and Charleston comorbidity score, all five components of qPitt were independently associated with mortality: temperature
Cressman A, MacFadden D, Verma A, et al.
AbstractBackgroundPhysicians face competing demands of maximizing pathogen coverage, while minimizing unnecessary use of broad-spectrum antibiotics when managing sepsis. We sought to identify physicians’ perceived likelihood of coverage achieved by their usual empiric antibiotic regimen, along with minimum thresholds of coverage they would be willing to accept when managing these patients.MethodsWe conducted a scenario-based survey of internal medicine physicians from across Canada using a 2 x 2 factorial design, varied by infection source (undifferentiated vs. genitourinary) and severity (mild vs. severe) denoted by the Quick Sepsis Related Organ Failure Assessment (qSOFA) score. For each scenario, participants selected their preferred empiric antibiotic regimen, estimated the likelihood of coverage achieved by that regimen and considered their minimum threshold of coverage.ResultsWe had 238 respondents including 87 (36.6%) residents and 151 attending physicians (63.4%). The perceived likelihood of antibiotic coverage and minimum thresholds of coverage for each scenario were: 1) severe undifferentiated 90% [interquartile range (IQR) 89.5–95.0] and 90% [IQR 80–95], 2) mild undifferentiated 89% [IQR 80–95] and 80% [IQR 70–89.5], 3) severe GU 91% [IQR 87.3–95.0] and 90% [IQR 80.0–90.0], and 4) mild GU 90% [IQR 81.8–91.3%] and 80% [IQR 71.8–90]. Illness severity and infectious diseases specialty predicted higher thresholds of coverage whereas less clinical experience and lower self-reported prescribing intensity predicted lower thresholds of coverage.ConclusionPathogen coverage of 80% and 90% are physician-acceptable thresholds for managing patients with mild and severe sepsis from bacterial infections. These data may inform clinical guidelines and decision-support tools to improve empiric antibiotic prescribing.
Lewis JM, Henrion M, Rylance J.
To the Editor Dr Rudd and colleagues concluded that the quick Sequential (Sepsis-Related) Organ Failure Assessment (qSOFA) score was superior to the systemic inflammatory response syndrome (SIRS) score and a baseline risk model in predicting in-hospital mortality in low- and middle-income countries (LMICs), an issue that has been debated since its introduction in the Sepsis-3 definitions. We are concerned that the treatment of missing data may have introduced significant bias.
Rudd KE, Seymour CW, Angus DC.
In Reply We agree with Dr Lewis and colleagues that missing data can be an important limitation in clinical research, including our analysis of the predictive validity of the qSOFA score and SIRS criteria. There are 2 issues related to missing data: (1) why missing data are present and (2) the approach to missing data during analysis. First, missing data were present in all 9 cohorts included in the study. Many sites lacked electronic health record systems, had limited medical staff available to collect and record serial vital signs, and were unable to routinely perform laboratory testing for every patient with suspected infection because of limited laboratory and financial resources. Given this reality, the diagnosis of sepsis in LMICs will not always be informed by complete data. Therefore, it is useful for clinicians in low-resource settings to understand the performance of alternative scoring systems in situations in which some variables, though important predictors of clinical outcome, may be missing.
Iram Yunus, Anum Fasih, Yanzhi Wang
by Iram Yunus, Anum Fasih, Yanzhi Wang
Objective The primary objective of this study was to determine the correlation between procalcitonin values and illness severity by evaluating the degree of end organ dysfunction using the Sequential Organ Failure Assessment score, length of stay and the severity of sepsis (sepsis alone vs. septic shock), The hypothesis that procalcitonin values would be higher in sicker patients was formulated before data collection began. Secondary outcomes studied in relation to procalcitonin levels included infection characteristics such as the site of infection, microbial agent and dialysis dependent CKD. Design Unblinded retrospective cohort study. September 2014-December 2016. Setting 364 patients with a diagnosis of sepsis or severe sepsis who were admitted to the general medical ward and ICU at Methodist Medical Center and Proctor Hospital in Peoria, Illinois, USA. Results This study demonstrates the following: Weak positive correlation between procalcitonin and SOFA score. Negligible correlation with length of stay. Higher values in patients who died than in patients who survived to discharge (p = 0.058). Sensitivity and specificity of procalcitonin for septic shock was 63 and 65% respectively. Sites typically infected by gram negative bacteria have higher procalcitonin values than sites infected by gram positive bacteria (p = 0.03). Higher procalcitonin in bacteremia than non-bacteremic infections (p = 0.004). Higher procalcitonin in dialysis-dependent CKD patients (p = 0.020). Conclusions Procalcitonin has a higher specificity for bacterial infections than other acute phase reactants. Although initial procalcitonin value may be helpful in the determination of illness severity, it is not always a reliable prognostic indicator and carries little significance as a standalone value. Procalcitonin values may be influenced by preexisting comorbid conditions such as chronic kidney disease, which are associated with higher procalcitonin values at baseline. Procalcitonin can provide invaluable information when viewed as one piece of a clinical puzzle, and is most powerful when the interpreting physician is aware of how values are influenced by the different clinical scenarios presented in this article.
Community acquired bloodstream infection (CABSI) in low- and middle income countries is associated with a high mortality. This study describes the clinical manifestations, laboratory findings and correlation of SOFA and qSOFA with mortality in patients with CABSI in northern Vietnam.
This was a retrospective study of 393 patients with at least one positive blood culture with not more than one bacterium taken within 48 h of hospitalisation. Clinical characteristic and laboratory results from the first 24 h in hospital were collected. SOFA and qSOFA scores were calculated and their validity in this setting was evaluated.
Among 393 patients with bacterial CABSI, approximately 80% (307/393) of patients had dysfunction of one or more organ on admission to the study hospital with the most common being that of coagulation (57.1% or 226/393). SOFA performed well in prediction of mortality in those patients initially admitted to the critical care unit (AUC 0.858, 95%CI 0.793–0.922) but poor in those admitted to medical wards (AUC 0.667, 95%CI 0.577–0.758). In contrast qSOFA had poor predictive validity in both settings (AUC 0.692, 95%CI 0.605–0.780 and AUC 0.527, 95%CI 0.424–0.630, respectively). The overall case fatality rate was 28%. HIV infection (HR = 3.145, p = 0.001), neutropenia (HR = 2.442, p = 0.002), SOFA score 1-point increment (HR = 1.19, p
Viriya Hantrakun, Ranjani Somayaji, Prapit Teparrukkul, Chaiyaporn Boonsri, Kristina Rudd, Nicholas P. J. Day, T. Eoin West, Direk Limmathurotsakul
by Viriya Hantrakun, Ranjani Somayaji, Prapit Teparrukkul, Chaiyaporn Boonsri, Kristina Rudd, Nicholas P. J. Day, T. Eoin West, Direk Limmathurotsakul
Infection and sepsis are leading causes of death worldwide but the epidemiology and outcomes are not well understood in resource-limited settings. We conducted a four-year prospective observational study from March 2013 to February 2017 to examine the clinical epidemiology and outcomes of adults admitted with community-acquired infection in a resource-limited tertiary-care hospital in Ubon Ratchathani province, Northeast Thailand. Hospitalized patients with infection and accompanying systemic manifestations of infection within 24 hours of admission were enrolled. Subjects were classified as having sepsis if they had a modified sequential organ failure assessment (SOFA) score ≥2 at enrollment. This study was registered with ClinicalTrials.gov, number NCT02217592. A total of 4,989 patients were analyzed. Of the cohort, 2,659 (53%) were male and the median age was 57 years (range 18–101). Of these, 1,173 (24%) patients presented primarily to the study hospital, 3,524 (71%) were transferred from 25 district hospitals or 8 smaller hospitals in the province, and 292 (6%) were transferred from one of 30 hospitals in other provinces. Three thousand seven hundred and sixteen (74%) patients were classified as having sepsis. Patients with sepsis had an older age distribution and a greater prevalence of comorbidities compared to patients without sepsis. Twenty eight-day mortality was 21% (765/3,716) in sepsis and 4% (54/1,273) in non-sepsis patients (p
Shahin Gaini, Mette Marie Relster, Court Pedersen, Isik Somuncu Johansen
José Moreira, Ariane Paixão, Juliana Oliveira, Waldir Jaló, Ofélio Manuel, Rafaela Rodrigues, Alexandra Oliveira, Leonardo Tinoco, João Lima, Beatriz Grinsztejn, Valdiléa G. Veloso, André M. Japiassú, Cristiane C. Lamas
To compare the discriminatory capacity of the quick Sequential Organ Failure Assessment (qSOFA) versus the Systemic Inflammatory Response Syndrome (SIRS) score for predicting 30-day mortality and intensive care unit (ICU) admission in patients with suspicion of infection at an HIV reference center.
F. Wu, Y. Ye, X. Zhou
We read with interest the meta-analysis by Maitra et al. who found that quick Sequential (sepsis-related) Organ Failure Assessment (qSOFA) seemed to be a poorly sensitive predictive marker for in-hospital mortality in hospitalized patients with suspected infection . Though the review sounds comprehensive and scientific, we have some different views to address.
Meta-analyses of accuracy of the qSOFA to predict hospital mortality of patients with suspected infection show suboptimal performance of this abridged score. However, a score composed of only 3 clinical variables, such as the qSOFA or CRB can hardly be very accurate, but can serve as a warning integrated into clinical decision making, to help triaging patients in the ED. qSOFA does not help identifying infection. More complete, generic severity scores are nevertheless of major interest for stratification or analyses of epidemiolgical studies and clinical trials in septic patients.
International AIDS Conference (AIDS) 2020
6.07.2020 - 10.07.2020
International Liver Congress (ILC) 2020
27.08.2020 - 29.08.2020
World Sepsis Day
Det 8. videnskabelige nationale møde om infektiøs endokarditis
International Congress for Tropical Medicine and Malaria (ICTMM) 2020
20.09.2020 - 24.09.2020
COVID-19 retningslinje (2020)
National handlingsplan for antibiotika til mennesker (2017)
Retningslinjer til sundhedsprofessionelle vedr. håndtering af infektion med zikavirus (2019)
Infections in Patients Colonized with Extended-Spectrum Beta-Lactamase-Producing Enterobacterales – a Retrospective Cohort Study
30.07.2020Clinical Infectious Diseases Advance Access
Zoonoses: beyond the human–animal–environment interface
Ambulatory management of primary spontaneous pneumothorax: when less is more
Surgery for benign prostatic obstruction
Investing in surgery: a value proposition for African leaders
Hvad mener Professor Jens Lundgren om artiklen"Dolutegravir plus Two Different Prodrugs of Tenofovir to Treat HIV."?
Hvorfor anbefaler Professor Troels Lillebæk artiklen"The global prevalence of latent tuberculosis: a systematic review and meta-analysis."?
Hvorfor anbefaler Professor Lars Østergaard artiklen"Efficacy of antibiotic treatment in patients with chronic low back pain and Modic changes (the AIM study): double blind, randomised, placebo controlled, multicentre trial."?
Hvorfor anbefaler Professor Thomas Benfield artiklen"Oral versus Intravenous Antibiotics for Bone and Joint Infection."?
Hvad synes Professor Niels Obel om"Early, Goal-Directed Therapy for Septic Shock - A Patient-Level Meta-Analysis."?
© 2020 Dansk Selskab for Infektionsmedicin
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